Health inspection·January 10, 2024

§42 CFR §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: (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; 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. 22CCR § 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, handwashing facility, soap dispenser and individual towels. (b) The facility shall adopt, observe and implement written infection control policies and procedures. 22CCR §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. (c) Each facility shall establish and implement policies and procedures, including but not limited to: (3) Infection control policies and procedures. 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 confirmed 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 Department may require. Every fire or explosion which occurs in or the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. On 12/13/2023, the California Department of Public Health (CDPH) received a complaint indicating a new coronavirus (COVID-19, a highly contagious respiratory infection caused by a virus that could easily spread from person to person) outbreak (a sudden rise in the incidence of a disease criteria) in the facility. On 12/14/2023, the CDPH conducted an unannounced visit at the facility to investigate the COVID-19 outbreak. The facility failed to: 1. Report the facility's COVID-19 positive cases to the Department of Public Health Licensing and Certification (CDPH). 2. Implement it's policy and procedure (P&P) titled "Infection Prevention and Control Program", which indicated outbreak management was a process of preventing the spread of infection to other residents and reporting the information to appropriate public health authorities. 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 75- year-old female, admitted on 3/3/2023, and was re-admitted to the facility on 6/3/23 with diagnosis of hypertension (high blood pressure), acute upper respiratory infection (a contagious infection of your upper respiratory tract), and cerebral infraction (occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it). A review of Resident 1 ' s Minimum Data Set (MDS-an assessment and care planning tool), dated 12/5/23, indicated Resident 1 had clear speech, the ability to express ideas and wants, and clear comprehension (understands). The MDS indicated Resident 1 required moderate assistance (helper does more than half the effort) with toileting, shower/bath, and personal hygiene. A review of Resident 1 ' s "COVID-19 Point of Care (POC) Test Result", dated 12/6/23 indicated Resident 1 was positive for COVID-19. A review of Resident 1 ' s Situation, Background, Assessment and Recommendation (SBAR) Communication Form, dated 12/6/23 at 2:15 a.m., indicated Resident 1 was observed with a runny nose, and the resident's COVID-19 test was positive. A review of Resident 1 ' s care plan created on 12/6/23, indicated Resident 1 required isolation precautions due to COVID-19 positive test result on 12/6/2023. The care plan interventions included to monitor Resident 1 for change in condition and notify the Medical Doctor, instruct Resident 1, family, and visitors regarding proper use of personal protective equipment, and observe contact isolation precautions. A review of Resident 2 ' s admission record dated 12/14/23, indicated Resident 2 was a 77-year-old male, admitted to the facility on 11/13/23 with diagnosis of hypertension, cerebral infarction, and cognitive communication deficit (difficulty with thinking and how someone uses language). A review of Resident 2 ' s MDS, dated 11/16/23, indicated Resident 2 had unclear speech, difficulty communicating some words or finishing thoughts. A review of Resident 2 ' s POC Test Result dated 12/9/23 indicated Resident 2 was positive for COVID-19. A review of the "eInteract Change in Condition (COC) Evaluation V5" dated 12/9/23, indicated Resident 2 had a on and off cough, and a fever 103.5. A review of Resident 2 ' s Physician order dated 12/9/23, indicated to transfer Resident 2 to the general acute care hospital (GACH) due to fever and on and off cough for further evaluation and management. During an interview on 12/21/23 at 1:50 p.m., with the Infection Preventionist (IP), the IP stated the COVID-19 outbreak was reported to the Department of Public Health and Red cap (CDPH Infection Control Unit) only because Resident 1 and Resident 2 tested positive with the Antigen (rapid COVID-19 test) test. The IP stated she thought she was following the facility's P &P. The IP stated the lack of reporting to CDPH Licensing unit had no effect on the residents. A review of the All facilities Letter (AFL, a letter from the Center for Health Care Quality, Licensing and Certification (L&C) Program to health facilities that are licensed or certified by L&C ) 23-09, dated 1/18/23, indicated the AFL reminds licensed health facilities of requirements to report outbreaks and unusual infectious disease occurrences to their local health department (LHD) and Licensing and Certification District Office and provides investigation and reporting thresholds for reporting for COVID-19. This AFL is pursuant to Title 17 CCR sections 2500, 2501, and 2502, and to their Licensing and Certification District Office pursuant to Title 22 CCR sections 70737, 70739, 72523, 72539, and 72541. A review of the facility ' s P &P titled "Infection Prevention and Control Program", dated 6/2021, indicated outbreak management was a process to determine the presence of an outbreak, manage the affected resident, prevent the spread of infection to other residents, and report the information to appropriate public health authorities. The facility failed to: 1. Report the facility's COVID-19 positive cases to the CDPH. 2. Implement its P &P "Infection Prevention and Control Program", which indicated outbreak management was a process to prevent the spread of infection to other residents and reporting the information to appropriate public health authorities. 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. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of residents.