Health inspection·January 21, 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. §483.80(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: §483.80(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; §483.80(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. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. T. 22 §72523 (c)(3) (c) Each facility shall establish and implement policies and procedures, including but not limited to: (3) Infection control policies and procedures. § 72321. Nursing Service -Patients with Infectious Diseases. (a) Patients with infectious diseases shall not be admitted to or cared for in the facility unless the following requirements are met: (1) A patient suspected of or diagnosed as having an infectious or reportable communicable disease or being in a carrier state who the attending officer determines is a potential danger, shall be accommodated in a room, vented to the outside, and provided with a separate toilet, hand-washing facility, soap dispenser and individual towels. (2) There shall be: (A) Separate provisions for handling contaminated linens. (B) Separate provisions for handling contaminated dishes. (b) The facility shall adopt, observe and implement written infection control policies and procedures. These policies and procedures shall be reviewed at least annually and revised as necessary. (c) The following shall be available in each nurse's station: (1) The facility's infection control policies and procedures. (2) Name, address and telephone numbers of local health officers. The facility failed to follow the aforementioned regulations by failing to follow their policies and procedures for infection control during the Coronavirus Disease 2019 outbreak (COVID 19, a mild to severe respiratory illness that is airborne and is spread from person to person or by contact with infectious material such as respiratory droplets in the air and to a lesser degree on high touch surfaces in the environment). The facility did not train their staff in preparation for a COVID19 outbreak after receiving the Quality, Safety and Oversight group (QSO) letter "QSO-20-20-All" letter, dated 3/23/20 from the Centers of Medicare and Medicaid Services (CMS) and when staff did not implement the necessary infection prevention and control interventions to prevent the spread of COVID-19. The facility failed to screen for symptomatic staff and allowed staff (CNA 1) to work while exhibiting symptoms of COVID 19. The facility failed to separate COVID positive residents from their roommates without COVID 19 for up to three days, (Residents 14, 22, 25, and 27). The facility staff failed to wear a face mask to cover their mouth (AD and CNA 6) and multiple wore ponchos with no sleeves (CNA 3 and housekeepers) instead of disposable personal protective equipment (PPE) coverings with long sleeves when providing care or cleaning high touch areas in the COVID 19 unit. One resident (Resident 5) who had COVID 19 and dementia (a cognitive disease that affects behavior), roamed throughout the facility, both in and amongst the COVID positive and negative rooms. The rooms with COVID 19 resident's doors were not closed to prevent the spread of disease. The facility failed to ensure the cleaning solution used to clean high touch areas was effective to kill the COVID 19 virus. These deficient practices resulted in a widespread outbreak of COVID-19 and Residents 1-28 becoming COVID-19 positive. Residents 6, 11, 26, 27 and 28 were transferred to the acute hospital, Resident 24 was transferred to the acute hospital and expired (died), and Residents 22, 23, and 25 expired of the Corona Virus 2019 Disease. The Administrator (ADM) was notified verbally of the Immediate Jeopardy (IJ) on 4/11/20, at 12:30 p.m. The facility failed to implement infection control interventions that would prevent the spread of COVID-19. Through observation, interviews with the staff members and record reviews of the facility's documents, the facility showed they initiated the plan of action through in-services of employees regarding infection control. The IJ was abated on 4/29/20 at 12:00 p.m. Upon entering the facility on 4/9/20 at 9:15 a.m. three staff members were observed standing close to each other and not observing social distancing and talking with each other in the lobby. They were not wearing face shields. During an interview and concurrent observation with the Director of Staff Development (DSD) and the Director of Staff Development Consultant (DSDC) on 4/9/20 at 9:15 a.m., DSD stated the current facility census was 36. DSD stated that 19 of the 36 residents were COVID-19 positive, and a cumulative total of 27 residents had been confirmed COVID-19 positive. DSD stated that out of the 27 COVID-19 positive residents, six (Residents 6, 11, 24, 26, 27, and 28) had been sent to the acute hospital and two residents (22, 23, and 25) had expired in the facility. DSD stated a total of four staff members (two CNAs and two managers), who were COVID-19 positive with no symptoms, were still working. DSD stated twenty-five staff members were COVID-19 positive and staff who were COVID-19 positive cared for COVID-19 positive residents only, and staff who were COVID-19 negative cared for COVID-19 positive and COVID-19 negative residents. During an observation and concurrent interview with the DSD and DSDC while doing a facility tour on 4/9/20 at 10:45 a.m., the AD/CNA 6 (Activity Director/Certified Nursing Assistant 6) was observed in the hallway wearing a N95 mask that did not completely cover her mouth, and CNA 3 was in the hallway at the linen cart wearing a poncho covering with no sleeves. DSD stated separate sleeves were available and should be worn with the poncho to prevent contamination of the arms. Resident 5 was observed in the hallway on 4/9/20 at 10:45 a.m. without a mask. DSD stated this resident had dementia and was COVID-19 positive. DSD stated this resident wandered around the facility, refused to wear a mask and "touches everything". Review of Resident 5's care plan, dated 4/2/20, indicated Resident 5 was COVID-19 positive, and there were no interventions regarding him wandering around the facility addressed in a plan of care. During an observation while doing a facility tour on 4/9/20 at 10:45 a.m., Housekeeping staff were observed wearing ponchos. The housekeepers were cleaning high touch areas near a resident's room with an unlabeled bottle of solution. The housekeepers stated the solution was a 1-10 bleach mixture. The housekeepers were not able to describe the how long the solution should stay on a surface to be effective. During the tour, many rooms in the COVID-19 unit had the doors opened. DSD stated the residents preferred the doors open. Review of the facility's policy and procedure date revised 1/2012, titled "Isolation-Categories of Transmission-Based Precautions," indicated, "...1. Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent or control the spread of infection. Airborne Precautions 1. In addition to Standard Precautions, implement Airborne Precautions for anyone who is documented or suspected to be infected with microorganisms transmitted by airborne droplet nuclei (small-particle residue[5 microns or smaller in size] of evaporated droplets containing microorganisms that remain suspended in the air and can be widely dispersed by air currents within a room or over a long distance). 4. b. Keep the room door closed and the resident in the room. 5. a. All individuals must wear approved respiratory protection when entering the room. 6. a. The resident should only leave an isolation room when absolutely essential. 6. b. Someone who is on Airborne Precautions, should wear a mask when leaving the room or coming into contact with others..." During a telephone interview with Certified Nursing Assistant (CNA) 1 on 4/24/20 at 12:00 p.m., CNA 1 stated she was COVID-19 positive and the last day she worked at facility was 4/1/20. CNA 1stated she was not feeling well on 4/1/20-had body pain, sore throat and temperature of 99 degrees Fahrenheit. CNA 1 stated she had taken care of Resident 23 and Resident 21 who later tested COVID-19 positive. CNA 1 stated Resident 21 had a cough and a fever the last week of March, and Resident 23 started to decline and was coughing the last two weeks of March. CNA 1 stated the end of March, maybe March 20, the facility did not have any disposable masks or gowns, and the Director of Nurses (DON) and DSD told her to wear hospital gowns (cloth with short sleeves). CNA 1 had a personal mask from home, but the DON and DSD told her not to wear the mask, because the residents would "think she was sick." CNA 1 stated the facility did not tell her that staff members (CNA and RN) had tested positive for COVID-19, and when she left on 4/1/20, the residents (COVID-19 +) had not been separated from the COVID 19 negative (-) residents, leaving them at risk for exposure to the COVID 19 virus. During an interview with the DSDC on 4/11/20 at 9:31 a.m., DSDC stated on 3/21/20, a staff member (a CNA) told the facility via phone that she had a headache and fatigue. DSDC stated that staff member had last worked in the facility on 3/17/20. DSDC stated that staff member was tested for COVID-19 on 3/25/20 and confirmed COVID-19 positive on 3/27/20. DSDC stated the facility started mapping and tracking all the residents that staff member had cared for, and the co-worker she had been in contact with. DSDC stated the facility monitored signs and symptoms of the residents and staff members the COVID-19 positive staff member had been in contact with. DSDC stated eight out of fourteen of the residents tested were confirmed COVID-19 positive. DSDC stated on 3/29/20, a Registered Nurse (RN) had a temperature of 100.4 and fatigue. DSDC stated that RN last worked on 3/27/20, the RN had been in contact with the first confirmed COVID-19 positive staff member. DSDC stated the RN was tested for COVID-19 on 3/29/20 and was confirmed positive on 3/30/20. DSDC stated on 3/30/20, Resident 21, who was being monitored for COVID-19 due to exposure, was sent out to the acute hospital for left-side weakness. DSDC stated Resident 21 was confirmed COVID-19 positive at the hospital. DSDC stated on 3/30/20 Resident 11 was transferred from dialysis to the hospital and was confirmed COVID-19 positive on 4/1/20. Review of a facility undated document titled "(Facility) List of COVID Patients," indicated Resident 21 and Resident 11 were sent out to the hospital on 3/20/20 and were tested and confirmed COVID-19 positive at the hospital. This document indicated Resident 6 was sent out to the hospital on 4/1/20 and was tested and confirmed COVID-19 positive at the hospital. This document indicated Resident 24 was sent out to the hospital on 4/2/20 and was tested and confirmed COVID-19 positive on 4/2/20. This document indicated Resident 26 was sent to the hospital and was tested and confirmed COVID-19 positive on 4/6/20. Further review of this document indicated Residents 1, 2, 3, 4, 5, 7, 8, 9, 10, 12, 13, 14, 15, 16, 17, 18, 19, 20, 22, 23, 25, 27, and 28 were confirmed COVID-19 positive on 4/2/20. Review of facility's COVID-19 mapping records (records that tracked the room location and diseases that residents had), indicated mapping for COVID-19 residents started 4/2/20, and Resident 16 was roomed with a COVID-19 negative resident, Resident 14 was roomed with a COVID-19 negative resident, Resident 22 was roomed with a COVID-19 negative resident, Resident 27 was roomed with a COVID-19 negative resident and Resident 25 was roomed with a COVID-19 negative resident. Further review of the facility mapping records, indicated these residents were not moved and placed in a designated COVID-19 positive unit until 4/3/20. During a telephone interview with Licensed Vocational Nurse/Supervisor (LVNS) on 4/24/20 at 12:44 p.m., LVNS stated the residents were moved to separate units after the first round of COVID-19 testing for residents was done-4/3/20. During a telephone interview with CNA 2 on 4/24/20 at 12:21 p.m., CNA 2 stated the last day she worked in the facility was 3/31/20. CNA 2 stated prior to 3/31/20, the facility did not have any disposable gowns and the end of March, the facility was short of masks, and she was told only to wear a mask if she had a cough. CNA 2 stated on 3/31/20 another staff member told her that a resident was COVID-19 positive, but there was no training provided to her regarding COVID-19. Review of the facility's training records did not show any training for COVID-19 on 3/31/20. According to the Center for Medicare and Medicaid Services' (CMS) center for Clinical Standards and Quality, Safety and Oversight group (QSO) reference: QSO-20-20-All letter, dated 3/23/20, indicated " ...We are disseminating the Infection Control survey developed by CMS and CDC so facilities can educate themselves on the latest practices and expectations. We expect facilities to use this new process, in conjunction with the latest guidance from CDC, to perform a voluntary self-assessment of their ability to prevent the transmission of COVID-19 ..." According to the Center for Disease Control and Prevention (CDC) Guidance, updated 4/13/20, indicated healthcare personnel "who enter the room a patient with known or suspected COVID-19 should adhere to Standard Precautions and use a respirator (or facemask if a respirator is not available), gown, gloves and eye protection ...Ensure that HCP are educated, trained, and have practiced the appropriate use of PPE prior to caring for a patient, including attention to correct use of PPE and prevention of contamination of clothing, skin, ..." During an interview with the DSD on 4/11/20 at 10:22 a.m., DSD stated she had talked to the county public health department on 3/27/20 and learned a staff member was COVID-19 positive. DSD stated the residents who were suspected of COVID-19 were monitored every shift (three shifts in 24 hours). During an interview with the DSDC on 4/16/20 at 12:44 p.m. DSDC stated prior to 4/1/20, the facility used a line listing for influenza to monitor resident s