Other·April 8, 2021

F880 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. (a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: (a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; (a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. (a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. (e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. (f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. On 8/7/20, an unannounced visit was conducted at the facility to conduct a Federal Infection Control Survey due to a COVID-19 (a mild to severe illness that is caused by a coronavirus and is transmitted chiefly by contact with infectious material [such as respiratory droplet] and is characterized by fever, cough, and shortness of breath and may progress to pneumonia and respiratory failure) outbreak in the facility. Based on observation, interview, and record review, the facility failed to prevent the spread of COVID-19 infection when: 1. Five of five sampled staff (Licensed Vocational Nurse/Personal Protective Equipment Coach [LVN/PPEC] 1, Certified Nursing Assistant [CNA] 2, Licensed Vocational Nurse [LVN] 1, CNA 1 and LVN/PPEC 2) used N95 masks (a type of respiratory device which removes particle from the air that are breathed through it) several days consecutively without rotation and training on the reuse of the N95 mask. 2. Used face shields (a mask typically made of clear plastic that protects the mucous membranes of the eyes, nose, and mouth during patient-care procedures and activities that carry the risk with generating splashes of blood, body fluids, excretions or secretions) were stacked and stored on top of each other. 3. One of one sampled staff (Housekeeper [HSK]) 1 was not wearing a face mask (a protective mask covering the nose and mouth to prevent yourself from breathing bad air or from spreading germs) when in the facility. 4. Contact tracing (is an intervention where an initial case with confirmed infection is asked to provide information about contact people who were at risk of acquiring infection from the initial case within a given time period before the positive test result), monitoring, cohorting (imposed grouping, such as health care workers, potentially exposed to designated diseases) and reporting to LHD (Local Health Department) and CDPH (California Department of Public Health) were not immediately implemented when one of 17 sampled staff, (CNA) 5, was confirmed positive for COVID-19 on 7/29/20. 5. Five of 17 sampled staff (CNA 3, CNA 4, CNA 5, CNA 6 and CNA 7) positive for COVID-19 returned to work prior to recovery. These failures resulted in 27 of 29 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, Resident 13, Resident 14, Resident 15, Resident 16, Resident 17, Resident 18, Resident 19, Resident 20, Resident 21, Resident 22, Resident 23, Resident 24, Resident 25, Resident 26, Resident 27) and 17 of 51 sampled staff (LVN 2, LVN 3, CNA 1, CNA 3, CNA 4, CNA 5, CNA 6, CNA 7, CNA 8, CNA 9, CNA 10, CNA 11, CNA 12, CNA 13, CNA 14, CNA 15, and Activity Director [AD]) in the facility testing positive for COVID-19. 1. During an interview on 8/6/20, at 3:40 PM, with LVN/PPEC 1, LVN/PPEC 1 stated, the staff must wear the individual N95 mask for 48 hours and store the mask in a sandwich container, labeled day 1, day 2, and day 3. LVN/PPEC 1 was unaware how many days a staff could wear an N95 mask before replacing it. During a concurrent observation and interview on 8/6/20, at 3:55 PM, with CNA 2, in the yellow zone (designated area for residents that have been exposed to COVID-19), CNA 2 was observed wearing an N95 mask. CNA 2 stated she had been using the same mask four days in a row. CNA 2 stated "No one has given me anymore. . . This is my fourth day to work, yes; I've used this mask four times in a row." During an interview on 8/6/20, at 3:57 PM, with LVN 1, LVN 1 stated the N95 mask should be used two to three days or until soiled. LVN 1 stated he was unaware how many times he wore his N95 mask. During a concurrent observation and interview on 8/6/20, at 4:02 PM, with CNA 1, CNA 1 was wearing an N95 mask. CNA 1 stated she had worn the N95 mask for two consecutive days. She also stated she has not been trained on how to rotate the N95 mask or trained to know how many times a person should wear the N95 mask before disposing it. During a concurrent observation and interview on 8/6/20, at 4:47 PM, with LVN/PPEC 2, in the red zone (COVID-19 positive designated unit), LVN/PPEC 2 was observed wearing an N95 mask. LVN/PPEC 2 stated she receives one N95 mask and three Styrofoam containers to store her mask. LVN/PPEC 2 stated the containers are dated and labeled day one, day two, day three and she rotates her one N95 mask between the three containers. LVN/PPEC 2 also stated she also wore the N95 mask she was currently wearing, on 8/4/20 and 8/5/20. She stated after three days of wearing the N95 mask consecutively, she will throw away the N95 mask and containers, and then she receives a new N95 mask and three containers. During a concurrent interview and review of the facility training record on 8/7/20, at 9:52 AM, with the Infection Preventionist (IP- are the person who specializes in preventing infection), the IP stated, the facility had implemented extended use of N95 and each employee was given three N95 masks and three containers. They label each container day 1, day 2 and day 3. The employee wears the mask and then stores the mask in the day 1 container; the employee wears the N95 mask on day 2, and stores the mask in the day 2 container; the employee wears the N95 mask on day 3, and stores the mask in the day 3 container. After using each N95 three times, the employee discards the mask and then receives a new set to include an N95 mask and containers. The IP was unable to provide evidence she trained staff on the extended use of the N95 masks. IP stated there was no lesson plan for extended use of the N95 mask and staff had not completed competencies. During a review of the facility's policy and procedure (P&P) titled, "COVID-19 Facility Exposure Management," undated, the P&P indicated, "Employees may utilize extended use techniques with masks and eye protection when caring for residents...Staff competencies and observations of daily handwashing and PPE procedures must be completed by the facility management staff." During a review of the "Centers for Disease Control and Prevention (CDC) Strategies for Optimizing the Supply of N95 Respirators" updated on 4/2019, it indicated, "Training on indications for use of N95 respirators-It is important that HCP [Health Care Personnel] be trained on indications for use of N95 respirators. The OSHA Respiratory Protection standard requires employers to provide respirator training to an employee prior to use in the workplace. Limited re-use of N95 respirators-One effective strategy to mitigate the contact transfer of pathogens from the respirator to the wearer could be to issue each HCP who may be exposed to COVID-19 patients a minimum of five respirators. Each respirator will be used on a particular day and stored in a breathable paper bag until the next week. This will result in each worker requiring a minimum of five N95 respirators if they put on, take off, care for them, and store them properly each day. This amount of time in between uses should exceed the 72 hour expected survival time for SARS-CoV2 (virus that caused COVID-19). HCP should still treat the respirator as though it is still contaminated. . . " 2. During a concurrent observation and interview on 8/6/20, at 3:40 PM, with LVN/PPEC 1, in the yellow zone, multiple face shields were stacked on top of each other on two tables near the entrance/exit of the yellow zone. LVN/PPEC 1 confirmed the findings and stated, staff share the face shields, in the yellow zone. During a concurrent observation and interview on 8/6/20, at 3:55 PM, with CNA 2, multiple face shields were stacked on a bedside table in the hallway, in between the yellow zone entrance/exit and a resident room. The stacked face shields were open to air and accessible to staff and residents. CNA 2 stated all face shield were shared by all staff working in the yellow zone. CNA 2 stated the staff spray face shields with a disinfectant after each use and stacked after it was dry. During a concurrent observation and interview on 8/6/20, at 4:25 PM, with LVN/PPEC 2, in the red zone, there was a sign inside the entry/exit door of the unit on the right and left side of the hall that indicated, donning (clean area for employees to put on PPE) and a doffing (area for removal of PPE) sign on the right side of the hallway. Also noted several face shields stacked on top of one another on a table on the left side of the hall that contained staff names. LVN/PPEC 2 confirmed the findings and stated, the staff are to put the face shields in the doffing area and nurses are responsible to sanitize the face shields after use and place in the donning area. LVN/PPEC 2 stated, with two donning signs it was confusing to determine the clean side from the dirty side. During a concurrent observation and interview on 8/7/20, at 10 AM, with LVN/PPEC 2, two stacks of approximately 10 face shields were on a bedside table in the red zone hallway. Stacked face shields were open to air and accesible to staff and residents. LVN/PPEC 2 stated all positive and negative staff working in the red zone shared the face shields. LVN/PPEC 2 stated, "Each staff is responsible to spray a disinfectant on their own face shield after each use and after it's dry [sic] I stack them on the clean side." During a review of the "Centers for Disease Control and Prevention (CDC) Operational Considerations for Personal Protective Equipment in the Context of Global Supply Shortages for Coronavirus Disease 2019 (COVID-19) Pandemic: non-US Healthcare Settings" updated 5/5/20, it indicated, "Reuse: A. Reprocessing and reusing disposable face shields for one HCW [Healthcare Worker] to use on multiple patients with COVID-19 for a limited time-period (multiple shifts). This strategy is not consistent with best practices and therefore not recommended, but if adopted: A face shield should be dedicated to one HCW. They should be immediately reprocessed when they are visibly soiled, whenever they are removed such as when leaving the isolation area, and at least daily (after every shift) prior to putting them back on (See reprocessing guidance below). After reprocessing, a face shield should be stored in a transparent plastic container and labeled with the HCW name to prevent accidental sharing between HCW." 3. During a concurrent observation and interview on 8/6/20, at 3:28 PM, with HSK 1, outside the laundry room, HSK 1 went to the dining room with N95 mask on. HSK 1 was no longer wearing an N95 mask or facial mask when she went back to the laundry room to gather her personal belongings. She spoke with two other laundry staff who were less than six feet from her. HSK 1 confirmed the findings and stated staff should wear a facial mask when inside the facility. During an interview on 8/6/20, at 3:40 PM, with LVN/PPEC 1, LVN/PPEC 1 stated, "The staff should have a facial mask on after removing their N95 mask . . ." During an interview on 8/6/20, at 5:05 PM, with the CNO, the CNO stated she expects staff to wear a facial mask when in the facility. During a review of the "Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic" updated 7/15/20, it indicated "HCP should wear a facemask at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers." 4. During a concurrent observation and interview on 8/7/20, at 10:05 AM, with CNA 5, in the red zone, CNA 5 stated she went to her own clinic and received a COVID-19 test on 7/28/20, and had received her positive test result on 7/29/20. CNA 5 stated she developed COVID-19 symptoms including a runny nose on the day she tested (7/28/20), a sore throat three days after being tested (7/31/20), and a headache two days ago (8/5/20). CNA 5 stated she notified the Assistant Administrator (AA) of her positive test result on 7/29/20 and AA notified her on 8/6/20 to return to work on 8/7/20. During an interview on 8/7/20, at 10:05 AM, with IP, IP stated she was aware CNA 5 had tested positive for COVID-19 on 7/29/20. IP stated she did not notify LHD of CNA 5's positive test result. During an interview, on 8/7/20, at 10:41 AM, with AA, AA stated CNA 5's husband had been exposed to COVID-19 and CNA 5 had decided to be tested on her own. AA stated CNA 5 was confirmed positive for COVID-19 on 7/29/20. AA stated CNA 5 was a part time employee of the facility and was not required to notify LHD or CDPH of CNA 5's confirmed positive test result. AA stated, "Why should I she's [CNA 5] not an employee. She's not full time, she's only part time." AA reviewed the facility "Daily Assignment Sign-In Sheet" and confirmed CNA 5 had worked on 7/28/20. AA stated she did not implement contact tracing, cohorting and/or monitoring to any exposed residents and staff after CNA 5's positive COVID-19 results. During an interview on 8/7/20, at 11:07 AM, with the CNO, the CNO stated, when CNA 5 tested positive for COVID-19 on 7/29/20, they should have implemented response-driven testing (contact tracing and testing in response to an outbreak). During an interview, on 8/7/20, at 2:31 PM, with the Local Health Department Physician (LHDP), LHDP stated the facility did not inform her of CNA 5's positive COVID-19 test on 7/29/20. LHDP stated it is the responsibility of the facility to notify LHD of any new COVID-19 positive residents and staff and all exposed residents and staff. LHDP stated the facility should have implemented contact immediately. During an interview on 8/7/20, at 11:08 AM, with the Administrator, the Administrator was unaware CNA 5 had tested positive for COVID-19. During a review of the facility's policy and procedure (P&P) titled, "Coronavirus Disease (COVID-19) Prevention and Control," undated, the P&P indicated, "The Infection Preventionist is respons