Other·February 3, 2023

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. 22 CCR § 72523. Patient Care Policies and Procedures. (a)Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 12/28/2022, the California Department of Public Health (Department) received a complaint regarding infection control practices not being implemented by the facility. On 12/29/2022, the Department conducted an unannounced visit at the facility to investigate the complaint. The facility failed to: 1. Separate COVID 19 (a potentially severe respiratory illness caused by a coronavirus and characterized by fever, coughing, and shortness of breath) positive residents (Resident 16 and 17) from COVID 19 negative resident (Resident 9) and COVID 19 positive residents (Resident 13 and 14) from COVID 19 negative resident (Resident 15). Resident 9 and 15 who were COVID 19 negative on 12/22/22 were sharing rooms with COVID 19 confirmed positive residents and tested positive on 12/29/22. 2. Initiate COVID 19 facility wide testing (testing all residents and staff) for facility staff exposed to COVID 19. The facility first identified COVID 19 case was on 12/23/22, and staff testing was conducted on 12/28/22. 3. Ensure Medical Doctor (MD) 2 who was examining residents in isolation (COVID 19 positive residents) area sanitized her personal stethoscope (medical instrument for listening to the action of someone's heart or breathing,) before and after used with Residents 11 and 24. Resident 24 was COVID 19 confirmed positive resident. 4. Ensure Director of Staff Development/Infection Preventionist Nurse (DSD/IPN) and Director of Nursing (DON) were aware of infection control guideline and the facility’s Infection Control Policies and Procedure (P&P) requiring confirmed COVID 19 positive residents be isolated from confirmed COVID 19 negative residents to mitigate (lessen) the transmission of COVID 19. 5. Ensure Certified Nurse Assistant (CNA) 3 donned (put on) gown and gloves when entering resident's rooms in the isolation area to deliver and setup food trays. As a result, Resident 9 and 15 was infected with COVID-19 infection and placed other residents, staff, visitors, and the community at a high risk for cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) and increased spread COVID-19 infection. 1. a) During a review of facility's census on 12/28/22, Resident 9 shared a room with Resident 16 and 17. During a review of Resident 9's "Admission Record" (AR), the AR indicated Resident 9 was a 74 year old female, admitted to the facility on 10/26/18 and was readmitted on 6/17/21 with diagnoses that included dementia (a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities), and epilepsy (seizure disorder - sudden, uncontrolled electrical activity in the brain that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness). During a review of Resident 9's Minimum Data Set ([MDS], a comprehensive assessment and care-screening tool), dated 11/17/22, the MDS indicated Resident 9 had severely impaired cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making. The MDS indicated Resident 9 was totally dependent with bed mobility, transfers, dressing, eating, toilet use, personal hygiene, and bathing. During a review of Resident 9's laboratory (lab) report dated, 12/23/22, the lab report indicated COVID 19 test result was negative. During a review of Resident 9's COVID 19 Resident Testing Record dated, 12/29/22 indicated Resident 9 test result was positive for COVID 19. During a review of Resident 9's care plan titled, Residents with COVID 19 or suspected COVID 19, dated, 12/29/22, the care plan indicated Resident 9 was positive for COVID 19. Goals included ensure implementation of guidelines regarding the care of all residents during the COVID 19 outbreak and be updated with most current guidelines. Interventions included place resident in a private room with own bathroom, room sharing might be necessary if there are multiple residents with known or suspected COVID 19, and keep door closed. During a review of Resident 16's MDS, dated 12/20/22, the MDS indicated Resident 16 had intact cognitive skills for daily decision making, was totally dependent on staff for bed mobility, transfers, toileting, personal hygiene, bathing, and required extensive assistance with dressing and eating. During a review of Resident 16's lab report dated, 12/23/22, the lab report indicated COVID 19 test result was positive. During a review of Resident 17's MDS dated 10/31/22, the MDS indicated Resident 17 had intact cognitive skills for daily decision making, was totally dependent for toilet use, required extensive assistance with bed mobility, transfers, dressing, personal hygiene, bathing, and required limited assistance with eating. During a review of Resident 17's lab report dated, 12/23/22, the lab report indicated COVID 19 test result was positive. b). During a review of facility's census on 12/28/22, Resident 15 shared a room with Resident 13 and 14. During a review of Resident 15's AR, the AR indicated Resident 15 was a 69 year old female, admitted to the facility on 1/23/20 and was readmitted on 3/22/21 with diagnoses that included multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves) and type 2 diabetes (a condition in which the body fails to metabolize (process) glucose (sugar) correctly). During a review of Resident 15's MDS, dated 10/21/22, the MDS indicated Resident 15 had intact cognitive skills for daily decision making, was totally dependent on staff for bed mobility, transfers, toileting, personal hygiene, and bathing, required extensive assistance with eating, and supervision with eating. During a review of Resident 15's lab report dated, 12/23/22, the lab report indicated COVID 19 test result was negative. During a review of Resident 15's COVID 19 Coronavirus Resident Testing Record dated, 12/29/22 indicated Resident 15 test result was positive for COVID 19. During a review of Resident 15's Care Plan titled, Residents with COVID 19 or suspected Covid-19, dated, 12/27/22, the care plan indicated resident 15 was positive for Covid 19. Goals included ensure implementation of guidelines regarding the care of all residents during the COVID 19 outbreak and be updated with most current guidelines. Interventions included place resident in a private room with own bathroom, room sharing might be necessary if there are multiple residents with known or suspected COVID 19, and keep door closed. During a review of Resident 13's MDS dated 9/23/22, the MDS indicated Resident 13 had severely impaired cognitive skills for daily decision making, and was totally dependent with bed mobility, transfers, dressing, eating, toilet use, personal hygiene, and bathing. During a review of Resident 13's lab report dated, 12/23/22, the lab report indicated COVID 19 test result was positive. During a review of Resident 14's MDS, dated 11/19/22, the MDS indicated Resident 14 had severely impaired cognitive skills for daily decision making, and was totally dependent for toilet use, personal hygiene, bathing, required extensive assistance with bed mobility, transfers, dressing, and required limited assistance with eating. During a review of Resident 14's lab report dated, 12/23/22, the lab report indicated COVID 19 test result was positive. During an interview on 12/29/22 at 8:25 a.m. with Registered Nurse (RN) 1, RN 1 stated the entire facility was changed to red zone/isolation with COVID 19 positive and COVID 19 negative residents cohorting in the same rooms together. RN 1 stated she does not know who made the decision to transition the entire facility to a red zone and she does not know the date the isolation began. During an interview on 12/29/22 at 9:07 a.m., with Licensed Vocational Nurse (LVN) 1, at Nursing Station 2, LVN 1 stated the entire facility was transitioned into a red zone and she was taking care of both COVID 19 negative and COVID 19 positive residents. LVN 1 stated her assignment included two rooms that have COVID 19 negative and COVID 19 positive residents cohorting together in the same rooms. LVN 1 stated the red zone should be designated for COVID 19 positive residents and with designated staff. LVN 1 stated having COVID 19 positive resident in the same room with COVID 19 negative residents will lead to all residents becoming infected with the COVID 19 virus and can lead to severe respiratory illness for residents with lots of medical problems. LVN 1 stated best practice was to have COVID 19 positive resident isolated in the red zone away from COVID 19 negative residents. During a concurrent observation and interview on 12/29/22 at 10:25 a.m., with LVN 3, in the east hall, LVN 3 stated she was taking care of Residents 13 and 14 who are confirmed COVID 19 positive, and isolated in a room with Resident 15 who was confirmed COVID 19 negative. LVN 3 stated she was also caring for Residents 16 and 17 who were COVID 19 positive and was isolated in a room with Resident 9 who was confirmed COVID 19 negative. Residents 13, 14, and 15 were observed isolated in the same room, and Residents 9, 16, and 17 were observed isolated in the same room. LVN 3 stated the red zone was for residents that are positive for COVID 19 and residents who were COVID 19 negative are at a higher risk of developing COVID 19 when the residents are in the same room with COVID 19 positive residents. During an interview on 12/29/22 at 3:39 p.m., with the DON, the DON stated the facility follows Center for Disease Prevention and Control (CDC), California Department of Public Health (CDPH), and Los Angeles County Department of Public Health (LAC-DPH) COVID 19 infection control guidance which indicate the red zone is designated for COVID 19 positive residents. The DON stated COVID 19 positive resident must be isolated in the red zone to contain the virus and prevent other residents and staff from becoming infected. The DON stated even after receiving negative COVID 19 test results for residents who were exposed to virus she made the decision to isolate all resident in place causing COVID 19 negative and COVID 19 positive resident to be in the same room. The DON stated best practice was isolate COVID 19 positive residents in red zone only. During an interview on 12/30/2022 at 11:40 a.m. with the DSD, the DSD stated Resident 9 and Resident 15 were initially confirmed negative with COVID 19 on 12/23/22 and was in the same room with COVID 19 positive residents. The DSD stated Resident 9 and Resident 15 tested positive with COVID 19 on 12/29/22. 2. During an interview on 12/29/22 at 10:50 a.m., with CNA 5, CNA 5 stated she was informed by the DSD/Infection Preventionist Nurse (IPN) the facility was in a COVID 19 outbreak starting on 12/26/2022. CNA 5 stated the first time she was tested during the current outbreak was on 12/28/22. During an interview on 12/29/22 at 11:40 a.m., with the DSD/IPN, the DSD/IPN stated the facility covid outbreak was confirmed on 12/23/22 after 14 residents and five (5) staff tested positive for COVID 19. DSD/IPN stated facility wide testing was conducted for staff on 12/28/22, five (5) days after the outbreak began. The DSD/IPN stated she was not aware of the facility's P&P for initial outbreak testing for staff during a covid outbreak. During an interview on 12/29/22 at 3:39 p.m., with the DON, the DON stated a COVID 19 outbreak is when 2 or more resident tested positive for COVID 19. The DON stated response testing for staff and residents should start immediately after knowledge of an outbreak. The DON stated she does not know why there was a delay in testing staff. The DON stated any delay in testing put residents, visitors, and staff at risk for developing and spreading the COVID 19 virus. 3. During a review of Resident 11's AR, the AR indicated Resident 11 was a 77 year old female, admitted to the facility on 12/17/22 with diagnoses that included hypothyroidism (underactive thyroid [small, butterfly-shaped gland located at the base of the neck]) and anemia (low number of red blood cells). During a review of Resident 11's COVID 19 resident testing record dated, 12/29/22, the lab report indicated COVID 19 test result was negative. During a review of Resident 24's AR, the AR indicated Resident 24 was a 82 year old male, admitted to the facility on 12/11/18 diagnoses that included dementia and hypertension (HTN - high blood pressure). During a review of Resident 24's lab report dated, 12/23/22, the lab report indicated COVID 19 test result was positive. During a concurrent observation and interview on 12/29/22 at 9:55 a.m., in the east hall and middle halls in the red zone, MD 2 was observed going into Resident 11's room and used her personal stethoscope to listen to Resident 11's chest. MD 2 placed her personal stethoscope on a belt hook/holder, removed her gown and gloves, exited the room and sanitized her hands. MD 2 did not sanitize personal stethoscope. MD 2 put on a gown and gloves, entered Resident 24's room and used her personal stethoscope and listen to Resident 24's chest. MD 2 removed her gown and gloves sanitized her hands and exited the room. MD 2 stated she was aware the facility was in a COVID 19 outbreak, and she know she should sanitize her stethoscope before and after using it on a resident in an isolation area. MD 2 stated she did not know facility had wipes to sanitize the stethoscope. During an interview on 12/29/22 at 3:39 p.m., with the DON, the DON stated it is the facility's policy that disposable stethoscope should be used in isolation rooms. The DON stated if personal stethoscope was used it must be sanitized before and after use on a resident to prevent cross contamination and to prevent the spread of COVID 19. 4. During an interview on 12/29/22 at 11:40 a.m., with the DSD/IPN, the DSD/IPN stated she did not receive guidance for the Department of Public Health (DPH) on converting the entire facility