Other·February 21, 2024

42 CFR §483.80 The facility must establish and maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. (a) The facility must establish an infection prevent and control program 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: (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. 22 CCR § 72521 Nursing Service- Patients with Infectious Diseases (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. 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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. (c) Each facility shall establish and implement policies and procedures, including but not limited to: (3) Infection control policies and procedures. 22 CCR § 72537 Reporting Communicable Diseases All cases of reportable communicable diseases shall be reported to the local health officer. 22 CCR § 72539 Reporting of Outbreaks Any outbreak or undue prevalence of infectious or parasitic disease or infestation shall be reported to the local health officer. 22 CCR § 72541 Unusual Occurrences Occurrences such as epidemic outbreaks, poisonings, fires major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirming in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having organized fire service, to the State Fire Marshall. On 1/8/2024, the California Department of Public Health (CDPH) received a complaint indicating the facility had 3 resident cases of the Coronavirus ([Covid-19] a highly contagious infection caused by a virus that could easily spread from person to person) which met the Covid-19 outbreak (a sudden rise in the incidence of a disease) criteria. On 11/11/2023, the CDPH conducted an unannounced visit at the facility to investigate the Covid-19 outbreak. The facility failed to: 1. Implement its policy and procedure (P&P) titled, “Infection Prevention and Control Program” which indicated to report outbreak information to the appropriate public health authorities. 2. Report the facility’s Covid-19 outbreak to the Licensing and Certification District Office per All Facilities Letter ([AFL] a letter from the Center for Health Care Quality, Licensing and Certification Program to health facilities that contained changes in requirements in healthcare, enforcement or general information that affected the health facility) 23-09 dated 1/18/2023. As a result, there was a high risk for an increase in Covid-19 cases in the facility, and placed residents, staff, and the community at risk for contracting the COVID-19 virus. A review of Resident 1’s Admission Record indicated Resident 1 was a 68-year-old female, admitted to the facility on 10/10/2023 with diagnoses including anemia (low blood iron) and alcohol abuse. A review of Resident 1’s History and Physical (H&P) dated 10/11/2023 indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 2’s Admission Record, indicated Resident 2 was a 68-year-old male, admitted to the facility on 12/28/2023 with diagnoses including diabetes (high blood sugar) and metabolic encephalopathy (brain disorder). A review of Resident 2’s H&P dated 12/29/2024, indicated Resident 2 had fluctuating capacity to understand and make decisions. A review of Resident 3’s Admission Record, indicated Resident 3 was a 71-year-old-female, admitted to the facility on 7/19/2021 with diagnoses including hyperlipidemia (elevated fat in the blood) and adult failure to thrive (state of decline that may be caused by diseases and impairments causing weight loss, poor nutrition and inactivity). A Review of Resident 3’s H&P dated 6/6/2023 indicated Resident 3 did not have the capacity to understand and make decisions. A review of Resident 1, 2 and 3’s “Covid-19 Antigen Test (testing method that provided results in 20 minutes or less) Result Form” dated 1/7/2024, indicated Resident’s 1, 2 and 3 tested positive for Covid-19 on 1/7/2024. During an interview on 1/11/2024 at 10:40 a.m., the Director of Nursing (DON) stated the facility should have reported the Covid -19 outbreak to the Licensing District Office however was not done. The DON stated it was important to report outbreaks immediately so they could be investigated in a timely manner and to prevent further transmission. A review of the facility’s P&P titled, “Infection Control Program” revised on 5/1/2020 indicated it was the facility’s policy to follow Covid-19 protocols including regulatory agencies’ directives (Centers for Disease Control, CDPH, County Public Health). The P&P indicated outbreak management was a process that consisted of determining the presence of an outbreak, managing the affected residents, preventing the spread to other residents, and reporting the information to the appropriate public health authorities. A review of AFL 23-09 titled, “Coronavirus Disease 2019 (Covid-19) Outbreak Investigation and Reporting Thresholds” dated 1/18/2023 indicated licensed health facilities were required to report outbreaks and unusual infectious disease occurrences to their local health department and to their Licensing and Certification District Office. The facility failed to: 1. Implement its P&P titled, “Infection Prevention and Control Program” which indicated to report outbreak information to the appropriate public health authorities. 2. Report the facility’s Covid-19 outbreak to the Licensing and Certification District Office per AFL 23-09 dated 1/18/2023. As a result, there was a high risk for an increase in Covid-19 cases in the facility, and placed residents, staff, and the community at risk for contracting the COVID-19 virus. This violation had a direct or immediate relationship to the health, safety, or security of residents.