Other·June 28, 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. §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. 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 5/14/2024, the California Department of Public Health (CDPH) conducted annual recertification survey. The facility failed to: 1. Implement infection control practices to prevent the spread and transmission of multidrug resistant organism ([MDROs]- microorganisms, predominantly bacteria that are resistant to one or more classes of antimicrobial agents) in the facility. 2. Ensure a personal protective equipment ([PPE]-equipment used to prevent or minimize exposure to hazards) was accessible and readily available to staff while providing direct care to residents at high risk of acquiring MDRO. 3. Ensure 11 residents were placed on Enhance Barrier Precaution ([EBP]- use of a gown and gloves for residents with wounds, indwelling devices such as a urinary catheter (a flexible tube that collects urine from the bladder to a drainage bag), gastrostomy tube ([GT]-a tube surgically inserted through the abdomen wall directly into the stomach for administration of medication and nutrition) and tracheostomy (a surgical opening in the neck for breathing). The following 11 residents are: a. Resident 247 who had a left heel deep tissue injury ([DTI]- when blood flow to an area is diminished or absent causing a pressure injury). b. Resident 246 who had an indwelling urinary catheter, colostomy (surgical opening for large intestine through the belly to allow stool to leave the body through the large intestine) and Stage 4 (full thickness skin and tissue loss) pressure ulcer (localized damage to the skin and/or underlying soft tissue) to the sacral area (above the tail bone) extending to buttocks and back. c. Residents 36, 37,38, 1, 9 and 346) who had GTs. d. Resident 1 who had a tracheostomy, and a Stage 3 pressure ulcer. (pressure ulcer that extend through the skin into deeper tissue and fat). e. Residents 96 and 246 with a Stage 4 pressure ulcers. g. Resident 17 with an open wound on the right hip. i. Resident 42 who had a pressure ulcer on the sacrum, right and left buttocks, right and left heel. 4. Ensure there was a signage for Enhanced Barrier Precaution posted or isolation cart (where personal protective equipment was stored with gown and gloves), placed outside the residents' rooms at the room entrance the to alert staff and visitors of EBP and prevent the spread of infection. 5. Have policies and procedures regarding the application of EBP for residents known to be colonized (presence of microorganism) with MDRO and residents with open wounds and/or invasive medical devices (inside the body). 6. Develop comprehensive EBP care plan for 11 residents with open wounds and indwelling medical devices such as indwelling urinary catheter, tracheostomy, and GT. 1. A review of Resident 247's Admission Record indicated, a 68-year-old male resident was admitted to the facility on 5/10/2024 with diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (mild loss of strength on one side of the body) following cerebral infarction (when blood flow to the brain is disrupted), type II diabetes mellitus (abnormal blood sugar), difficulty in walking, and muscle weakness. A review of Resident 247's Physician's Order Summary Report dated 5/15/24, indicated Resident 247 had a diagnosis of left heel DTI. The Physician's Order Summary Report indicated to apply heel protectors (padding that help protect the heel) to bilateral (both) heels daily. A review of Resident 247's History and Physical (H&P) dated 5/18/24 indicated Resident 247 had the capacity to understand and make decisions. During an observation on 5/14/2024 at 8:30 a.m., outside Resident 247's and 246's room there was no EBP signage and no isolation cart with PPEs readily available for staff to use before entering the residents' room. During an observation on 5/15/2024 at 4:30 p.m., outside Resident 247's room, the Physical Therapist ([PT 1]- a licensed professional aimed in the restoration, maintenance, and promotion of optimal physical function) was standing behind the closed privacy curtain at Resident 247's bedside. PT 1 was observed walking out from behind the closed privacy curtain wearing only gloves and no gown. During an interview on 5/15/24 at 5:00 p.m., PT 1, stated she was wearing gloves when providing physical therapy treatment to Resident 247. PT 1 stated she should have worn a gown and gloves to prevent the risk of cross contamination (transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) to other residents and staff. During an interview on 5/16/2024, at 2:04 p.m., the Infection Prevention Nurse (IPN), stated Residents 247, 246, 36, 37, 38, 1, 9, 346, 96,17 and 42 were not on EBP. The IPN stated PPEs should be readily accessible to staff who provides care to these residents. The IPN stated unfortunately, there were no PPEs available in front of residents' rooms for staff to use before entering their rooms. The IPN stated if staff did not follow the EBP they were increasing the risk of infection cross-contamination from affected residents to staff, other residents, and the community. The IPN stated he had not implemented EBP for Resident 247,246 ,36, 37, 38, 1, 9, 346, 96 17 and 42 with wounds and invasive medical devices. The IPN stated residents with an indwelling urinary catheter, GT, tracheostomy, and draining wounds should all be placed on EBP. The IPN stated there were no EBP care plans for all 11 residents with open wounds and invasive medical devices. The IPN also stated the facility did not have any policies and procedures on the application of EBP for residents with MDRO and those with open wounds and/or invasive medical devices. 2. A review of Resident 246's Admission Record indicated, a 48 year old male resident was admitted to the facility on 4/26/2024 with diagnoses including paraplegia (no feeling in lower body), type II diabetes mellitus, a Stage 4 pressure ulcer on the left heel, a Stage 4 pressure ulcer unspecified part of the back, a Stage 4 pressure ulcer of the sacral (lower back) area, a Stage 4 pressure ulcer of the right buttock, a Stage 4 pressure ulcer of the right heel, rash and other nonspecific skin eruptions, an indwelling urinary catheter and a colostomy. A review of Resident 246's H&P dated 4/29/2024 indicated Resident 246 had the capacity to understand and make decisions. A review of Resident 246's Physician's Order Summary Report dated 4/27/2024 indicated to cleanse left ischium (lower hip bone), and right buttock pressure ulcers with Normal Saline (cleansing solution), pat dry, pack lightly with Calcium Alginate (type of wound dressing), cleanse left lower extremity extending to foot, right foot with Hibiclens(antibacterial cleansing solution), pat dry, apply Bacitracin (antibiotic), Nystatin powder ( treats fungal [yeast or mold] infections of the skin), and cover with Xeroform (type of dressing) every day shift. A review of Resident 246's Treatment Administration Record (TAR) dated 5/1/2024 indicated Resident 246 had a Stage 4 pressure ulcer to the right and left ischium a Stage 4 pressure ulcer on the left lower extremity extending to left foot Stage 4 pressure ulcer, a Stage 4 pressure ulcer to the right lower extremity extending to the right foot pressure ulcer Stage 4, a Stage 4 pressure injury to the buttock, a Stage 4 dorsal (the back portion of the body) pressure injury, an indwelling urinary catheter, and colostomy. 3. A review of Resident 346 Admission Record indicated a 77-year-old female resident was admitted to the facility on 5/9/2024 with diagnoses including GT, type 2 diabetes mellitus, abnormalities of gait (trouble walking) and mobility. A review of Resident 346's H&P dated 5/13/2024 indicated Resident 346 had the capacity to understand and make decisions. During an observation on 5/15/2024 at 8:35 a.m., outside Resident 346's room by the room entrance, there was no EBP signage displayed and no isolation cart with PPE readily available for use. 4. A review of Resident 96's Admission Record indicated a 60-year-old female resident was admitted to the facility on 4/25/2024 with diagnoses including GT, type II diabetes mellitus, abnormalities of gait and mobility. A review of Resident 96's H&P dated 4/25/2024 indicated Resident 96 had the capacity to understand and make decisions. During an observation on 5/15/2024 at 8:35 a.m., outside Resident 96's room by the room entrance, there was no EBP signage and no isolation car with PPEs, readily available before entering the room. During an observation on 5/15/2024 at 10:30 a.m., the Treatment Nurse (TN) 1 was observed while performing wound care to Resident 96 the TN 1 was only wearing gloves and not wearing a gown as required for EBP During an observation on 5/15/2024 at 3:00 p.m., the Occupational Therapist ([OT 1] profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) was observed wearing gloves while performing active range of motion exercises ([AROM]- full movement potential of a joint [where two bones meet]) to Resident 96 but was not wearing a gown. During an interview on 5/16/2024 at 11:06 a.m., the OT 1 stated he was not aware Resident 96 was on EBP. The OT 1 stated, he should have worn a complete PPE including gloves and gown when performing AROM to Resident 96. During an interview on 5/16/2024 at 2:17 p.m., the DON stated if infection control practices were not observed such as EBP, there was a high risk for cross contamination of infection and the possibility of spreading MDROs to other residents and staff. 5. A review of Resident 38's Admission Record indicated, a 64-year-old female resident was admitted to the facility on 3/17/2018 and re-admitted to the facility on 1/31/2022 with diagnoses including right hip open wound, atrial fibrillation (an irregular and very rapid heart rhythm), muscle wasting and atrophy (the wasting or thinning of muscle mass due to disuse or nerve problems). A review of Resident 38's Progress Notes, dated 7/1/2023, indicated, Resident 38 had the capacity to understand and make decisions. A review of Resident 38's Minimum Data Set ([MDS]- standardized assessment and care screening tool) dated 4/9/2024, indicated Resident 38 was independent with eating and oral hygiene. The MDS indicated Resident 38 needed set up or clean up assistance with toilet hygiene, upper body dressing, repositioning from sitting to lying, lying to sitting on the side of the bed, sitting to standing, transferring from bed to chair, and transferring to the toilet. The MDS indicated Resident 38 needed supervision or touching assistance with showering, rolling from left to right, transferring to the shower and walking. The MDS indicated Resident 38 needed partial and moderate assistance with lower body dressing, putting on and taking off footwear and personal hygiene. The MDS indicated Resident 38 was receiving nutrition through a GT. The MDS also indicated Resident 38 received care for a surgical wound. During an observation on 5/15/2024 at 8:35 a.m., outside Resident 38's room there was no EBP signage and no isolation cart with PPE readily available before entering the residents' room. During an interview on 5/16/2024 at 12:01 p.m., with Resident 38 in the hallway, Resident 38 stated he received wound care with a dressing change to the right hip weekly. Resident 38 stated on 5/15/2024 the TN (name unknown) only wore gloves when she did Resident 38 wound care dressing change. During an interview on 5/16/2024 at 12:03 p.m., the Licensed Vocational Nurse (LVN3stated she never wears a gown when changing Resident 38's wound dressing. 6. A review of Resident 37's Admission Record indicated, a 32-year-old male resident was admitted to the facility on 4/15/2024 with diagnoses including GT, and gastroesophageal reflux disease (GERD-condition in which the stomach contents move up into the esophagus [food pipe]). A review of Resident 37's MDS dated 2/8/2024 indicated Resident 37 had severe cognitive (ability to think, understand, learn, and remember) impairment in daily decision making. The MDS indicated Resident 37 was dependent (helper does all the effort) on staff for oral hygiene, upper body dressing, eating and dependent with shower/bathe self, lower body dressing. During an observation on 5/15/2024 at 8:30 a.m., outside Resident 37's room there was no EBP signage and no isolation cart with PPE readily available before entering the resident's room. 7. A review of Resident 36's Admission Record indicated a 91-year-old female resident was admitted to the facility on 4/15/2024 with diagnoses including GT, GERD, and dementia (loss of memory, language, problem-solving and other thinking abilities). A review of Resident 36's MDS dated 1/20/2024 indicated Resident 36 had moderate cognitive impairment for daily decision making. The MDS indicated Resident 36 was dependent on staff for personal hygiene, toileting, and shower/bathing. The MDS indicated Resident 36 had a GT. During an observation on 5/15/2024 at 8:30 a.m., outside Resident 36's room there was no EBP signage and no isolation cart with PPE readily available before entering the resident's room. 8. A review of Resident 17's Admission Record indicated, a 68-year-old male resident was admitted to the facility on 3/17/2018 and readmitted on 1/31/2022 with diagnoses including difficulty walking, and open wound to the right hip. A review of Resident 17's H&P dated 1/31/2024 indicated Resident 17 had the capacity to understand and make decisions. A review of Resident 17's MDS dated 4/9/24 indicated Resident 17 had an intact cognitive skill for daily decision making. The MDS indicated Resident 17 required partial to moderate assistance with lower body dressing and set up help with toileting and independent with eating. A review of Resident 17's TAR dated 4/30/2024 indicated Resident 17 had an open wound to the right hip. During an observation on 5/15/2024 at 8:30 a.