145825
02/14/2024
South Elgin Living & Rehab Center
746 West Spring Street South Elgin, IL 60177
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm or potential for actual harm
Based on observation, interview, and record review, the facility failed to apply the correct PPE (Personal Protective Equipment) prior to entering resident rooms who were COVID-19 positive. The facility also failed to post contact isolation and droplet isolation signage outside the rooms of residents who were COVID-19 positive.
Residents Affected - Some
This applies to 7 of 7 residents (R1, R2, R3, R4, R5, R6, R7) reviewed for COVID-19 infection control. The findings include: On February 13, 2024 at 09:49 AM, V5 (Housekeeper) entered R1 and R2's room wearing a surgical face mask and gloves. R1 and R2's room was under COVID-19 isolation. The signage outside the room showed a gown, gloves, N95, and face shield should be worn prior to entering COVID-19 isolation rooms. V5 finished cleaning the room and exited at 09:55 AM. V5 washed her hands and went to the next room wearing the same surgical face mask. At 10:45 AM, V5 said for residents under COVID-19 isolation, they should wear a gown, N95 face mask, and gloves. On February 13, 2024 at 11:51 AM, V6 (CNA/Certified Nurse Assistant) entered R3 and R4's room wearing a surgical face mask only. R3 and R4's room was under COVID-19 isolation. After exiting the room, V6 did not change his mask or perform hand hygiene. V6 said the residents were on isolation for COVID-19. V6 said the PPE guideline showed he was supposed to wear a face shield, gown, gloves, and an N95 face mask. V6 said he was supposed to put on all PPE (Protective Personal Equipment) prior to entering the room. On February 13, 2024 at 10:34 AM, V9 (CNA) entered R1 and R2's room without wearing a face shield. V9 removed his gown and gloves in the room and exited the room without changing his N95 face mask. On February 13, 2024 during the initial tour, R1, R2, R3, R4, R5, R6, and R7 did not have contact isolation and droplet isolation signage posted outside of their room door to notify staff and visitors what kind of isolation the residents were on. R1-R7's rooms had the following signs: ISOLATION, Do Not Enter Please see the nurse, and Use PPE (Protective Personal Equipment) When Caring for Patients with Confirmed or Suspected COVID-19. On February 13, 2024 at 12:07 PM, V7 (RN/Registered Nurse) said the residents on COVID-19 isolation had droplet and contact isolation implemented. V7 said the staff were supposed to wear gowns, N95's, goggles, and gloves while in the room. V7 said hand hygiene should be done before applying PPE and after removing PPE. V7 said the staff should wear PPE any time they enter the rooms under COVID-19 isolation. V7 said they could wear the same N95 face mask from a COVID-19 isolation room to another
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145825
145825
02/14/2024
South Elgin Living & Rehab Center
746 West Spring Street South Elgin, IL 60177
F 0880
room because there are limited supply of N95s.
Level of Harm - Minimal harm or potential for actual harm
On February 13, 2024 at 12:13 PM, V8 (RN) said the staff should wear a gown, N95 face mask, goggles, and gloves before going into a COVID-19 isolation room. V8 said all PPE should be removed and all new PPE should be worn going into another resident's room.
Residents Affected - Some On February 13, 2024 at 02:03 PM, V1 (DON/Director of Nursing) said the staff are supposed to perform hand hygiene and then apply an N95 mask, gloves, and the gown. V1 said the staff are not necessarily supposed to wear the face shields unless the resident has symptoms. V1 said she would request more information from the regional consultant. On February 13, 2024 at 02:41 PM, V10 (Regional Director of Clinical Operations) said when the staff go into the room, they should be wearing N95's, gowns, gloves, and face shields, which was according to their policy. V10 then said the CDC (Centers of Disease Control) website states staff do not have to wear face shields, and when asked, said the facility should be following their policy for COVID-19 PPE guidelines. The facility's COVID-19 Control Measures policy revised on November 7, 2022, showed All HCP [Health Care Professionals] must wear an N95 and eye protection when caring for all residents. HCP are to wear N95 and eye protection when facility is in outbreak, regardless of the Community Transmission Level. Additional PPE is to be utilized (gowns/gloves) when caring for residents with suspected or confirmed COVID-19. Contact Precautions- Post signage on door. Droplet Precautions- Post signage on door. The facility's Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19 undated document showed Preferred PPE- Use N95 or Higher Respirator, face shield or googles, one pair of clean, non-sterile gloves, and isolation gown. Acceptable Alternative PPEFace shield or googles, Facemask (N95 or higher respirators are preferred but facemasks are an acceptable alternative), One pair of clean, non-sterile gloves, and isolation gown.
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