Health inspection·January 8, 2021

F 880 §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. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. § 72521. Administrative Policies and Procedures. (b) All policies and procedures required by these regulations shall be in writing and shall be carried out as written. They shall be made available upon request to patients or their agents and to employees and the public. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the governing body or licensee. (c) Each facility shall establish at least the following: (2) Policies and procedures for patient admission, leave of absence, transfer, pass and discharge, categories of patients accepted and retained, rate of charge for services included in the basic rate, type of services offered, charges for extra services, limitations of services, cause for termination of services and refund policies applying to termination of services. § 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 11/23/2020, an unannounced visit was conducted at the facility to investigate a complaint regarding Infection Control. The facility failed to implement interventions to prevent and control the spread of COVID-19 (Coronavirus disease, a severe respiratory illness caused by virus and transmitted from person to person) in accordance to the facility's infection control policies and the Mitigation Plan (MP, a plan to reduce loss of life and impact of COVID-19 in the facility) by failing to: a. Implement a screening process, including checking for signs and symptoms of COVID-19, history of travel, any contact with positive COVID-19 persons and reminder to do hand hygiene upon entering and exiting the facility. b. Ensure the Screener (S1) disinfected pens and thermometer between staff and essential visitors' usage. c. Ensure Licensed Vocational Nurse 2 (LVN 2) and all facility staff were fit tested (a respirator fit test checks the right size and seal of the person who wears it, to prevent air leak) with the proper N95 masks (a particulate-filtering face piece respiratory that meets the US National Institute for Occupational Safety and Health [NIOSH] and filters at least 95% of airborne particles) and ensuring enough supply for all staff. d. Ensure Certified Nursing Assistant 2, 3, 4 (CNA2, 3, 4) and all staff wear the proper Personal Protective Equipment (PPE - protective clothing, goggles, or other garments or equipment designed to protect the wearer's body from serious workplace injury or illnesses) to provide care to residents in specific cohorting units (imposed grouping of people, such as residents potentially exposed to a designated disease, separation areas between Covid-19 and Non-Covid-19 unit). e. Ensure the facility had a clear designation of Cohorting units with the use of signages such as Green zone, Yellow zone and Red zone. Residents 2, 3, 6, 8 were in the Red zone and Resident 7 was in the Yellow zone. f. Ensure a full-time, dedicated Infection Preventionist (IP) was knowledgeable on cohorting (imposed grouping of people, such as residents potentially exposed to a designated disease) residents as per recommendation from the Public Health Nurse (PHN). g. Properly assess Resident 6 and Resident 8, who had suspected respiratory or infectious illness, every four hours or at least twice during each shift, to quickly identify residents who require transfer to a higher level of care. As a result, these deficient practices had the potential to result in spread of COVID-19 placing all 28 residents in the facility and staff at risk to be infected with COVID-19 and becoming seriously ill, leading to hospitalization and/or death. A review of the facility's census during onsite visits conducted on 11/12/2020, 11/23/2020, and 11/24/2020, indicated facility had 33, 28, and 25 residents in-house, respectively. a. On 11/12/2020 at 11:50 a.m., during an observation, one of the locked entrances of the facility indicated there was no personnel at the screening area. Licensed Vocational Nurse 1 (LVN 1) unlocked the door for the visitors, requested to complete the questionnaires and check each other's temperature via handheld thermometer. No other guidance was provided from LVN 1 to the visitors, such as hand hygiene. Upon observation, the facility had one surveillance log for both the staff and visitors. The log indicated there were missing temperatures upon exiting the facility for 5 of 6 places dated 11/11/2020. During a concurrent interview, LVN 1 stated the log should not have any missing areas since the facility staff should be checking temperatures before and after each shift to limit risk of infection. During an observation, on 11/12/2020 at 12:13 p.m., upon the other entrance to the facility, Licensed Vocational Nurse 2 (LVN 2) did not provide a reminder to the visitors regarding hand hygiene and stated that the unit did not have a screening log. LVN 2 verbalized that it was important to have a process of screening both staff and visitors for any signs and symptoms of infection before entering and exiting the facility to decrease transmission of infection. During an interview with the Director of Nursing (DON), on 11/12/2020 at 12:55 p.m., the DON stated the screening log for both the staff and visitors should be completed to monitor the spread of infection. A review of facility's Mitigation Plan (page 6), revised on 10/2/2020, indicated to limit transmission and spread of infectious disease throughout the facility, all incoming and outgoing staff shall be screened for symptoms of COVID-19, and a designee will be assigned to screen. All incoming and outgoing visitors must be screened for symptoms of COVID-19 temperature, cough and documented. b. During an observation, on 11/23/2020 at 2:50 p.m., a facility Screener checked the visitor's temperature via the forehead, without disinfecting the thermometer between visitors. During a concurrent interview, the DON stated the screener's job was to ask all the Covid-19 related questionnaires to all the staff and visitors, check the temperature, document and sanitize all the pens and thermometers in between use. A review of the facility's Mitigation Plan (page 6), revised on 10/2/2020, indicated under the Infection Prevention and Control section, staff shall clean and disinfect reusable equipment before and after each use. c. On 11/12/2020 at 12:13 p.m., LVN 2 was observed wearing a smaller N95 mask that appeared too tight. During a concurrent interview, LVN 2 stated staff needed to wear a N95 mask in the yellow zone and be fit tested with the proper N95 for protection. When asked about the size of his mask, LVN 2 stated he used a smaller size mask due to not having any bigger sizes in the facility. LVN 2 stated that the staff was not N95 fit tested. During an interview, on 11/12/2020 at 2:45 p.m., the DON stated the facility was waiting for a delivery of larger size N95 masks and that the Public Health Nurse provided the DON some suppliers for the N95 fit testing for the staff. The DON added that using the proper N95 fit can protect staff in getting infected with COVID-19. According to a review of the facility's line listing, LVN 2 tested positive for Covid-19 on 11/18/2020. A review of the facility's Mitigation Plan (page 7), revised on 10/2/2020, indicated under the Personal Protective Equipment (PPE) section, a designated employee would maintain a 14 day supply of PPE in the facility, would conduct daily PPE inventory, and report exact amount of PPE during the standup meeting. A review of the facility's policy titled, "Pandemic Infectious disease," undated, indicated during a COVID-19 "alert" period, the facility will assure adequate supplies for PPE and equipment so that cross contamination from patient to patient and staff to patient will not occur. The facility will ensure all staff have access to an appropriate amount of personal protective equipment for each patient seen daily. d. A review of Admission Record indicated Resident 7 was admitted to the facility on 9/25/2017 with diagnoses including Chronic Ischemic Heart Disease (an illness when the heart does not get enough blood and oxygen), and Type II diabetes mellitus (abnormal blood sugar level). During an observation in the yellow zone (a designated space for patient under investigation for Covid-19 under droplet precaution), on 11/12/2020 at 2:13 p.m., inside Resident 7's room, Certified Nursing Assistant 2 (CNA2) removed the N95 mask, kept it hanging on the neck, and then proceeded to donn (put on) the surgical mask (a loose-fitting disposable mask that protects the wearer's nose and mouth from contact with droplets, splashes and sprays that may contain germs). Once CNA2 saw she was being watched, CNA2 immediately placed the N95 mask on top of the surgical mask. During a concurrent interview, CNA2 stated the N95 mask should be worn at all times while in the yellow zone to prevent any spread of infection. CNA2 added that she changed it to a surgical mask because it was hard to breathe through the N95 mask. During an interview, on 11/12/2020 at 2:20 p.m., the DON stated and verified the N95 mask, face shields, goggle, gowns and gloves were needed in the yellow zone for protection. According to a review of the facility's line listing, Resident 7 tested positive for Covid-19 on 11/13/2020. A review of the facility's policy titled, "Transmission based Precautions and personal protective equipment," undated, indicated while in the yellow and red zones, N95 respirators should be worn. A review of an Inservice form, dated 11/10/2020, indicated CNA2 attended an in-service regarding review of Cohorting zones and PPE use by Infection Preventionist 1. During an observation in the red zone, on 11/24/2020 at 6:15 a.m., CNA3 was noted using a mask with an exhaust valve and not wearing a face shield. During a concurrent interview, CNA3 stated the mask with exhaust valve was not provided by the facility and that she preferred using this particular type mask because it was easier to breathe. CNA3 stated she did not like wearing the face shield because it fogs up her eyeglasses. CNA3 did not know if the mask was a NIOSH approved (National Institute for Occupational Safety and Health, responsible for conducting research and making recommendations for the prevention of work-related injury and illness.). During an interview, on 11/24/2020 at 6 a.m., LVN 3 stated that in the red zone, staff should wear N95 mask, face shield, gown and gloves at all times. A review of the in-service form dated 11/20/2020, indicated CNA3 attended an in-service regarding review of Cohorting zones and PPE use by the Infection Preventionist 1. A review of the facility's policy and procedure titled, "Transmission Based Precautions and Personal Protective Equipment (PPE)," undated, indicated the N95 respirators with an exhaust valve do not provide source control and should not be used in healthcare settings. During an observation on 11/24/2020 at 6:34 a.m., CNA4 was not wearing a disposable gown in the red zone. During a concurrent interview, CNA4 stated she just removed a soiled disposable gown and would get a new one by the front desk located in the PPE donning area. During an interview on 11/24/2020 at 6:40 a.m., LVN 3 stated extra disposable gowns were in the PPE donning area and the nurse's station. LVN 3 verbalized that once staff was inside the red zone, staff cannot go back in the same entrance to get PPE. LVN 3 added that staff needed to go out via one way exit and go back through the front door entrance where the location of the screening was located. During an interview, on 11/24/2020 at 7 a.m., the DON stated there was only one-way entrance going in the red zone and one-way exit out. A review of Facility's Mitigation Plan (page 7), revised on 10/2/2020, indicated necessary PPE shall be immediately available outside of the resident room for COVID-19 positive, Person Under Investigation (PUI) , and in other areas where resident care was provided and PPE was required. e. A review of Resident 2's Admission Record indicated the facility admitted the resident with diagnoses including Congestive Heart Failure (a heart disease in which the heart does not pump blood as well as it should), and Type II diabetes mellitus (abnormal blood sugar level). Resident 2 was located inside the red zone. A review of Resident 3's Admission Record indicated the facility admitted the resident with diagnoses including thrombocytopenia (condition that causes low levels of platelets, the cells that help blood clot [clumps of blood]). Resident 3 was located inside the red zone. A review of Resident 8's Admission Record indicated the facility admitted the resident on 1/28/2020 with diagnoses including hyperlipidemia (an abnormal high concentration of fats or lipids in the blood), and Osteoporosis (a condition in which the bones become weak and brittle). Resident 8 was located inside the red zone. During an observation on 11/12/2020 at 12:01 p.m., the facility did not have a clear designation between COVID-19 red zone or yellow zone units. Both entrances were observed with white plastic barriers inside and no signages were noted. During a concurrent interview, LVN 1 stated they were currently standing in the COVID-19 unit (red zone) and the other entrance was the yellow zone unit. LVN 1 worked in the red zone. During an observation in the red zone, on 11/12/2020 at 12:31 p.m., there were a few transmission- based precautions signages in between the rooms. Every room located in the red zone did not have proper transmission signages. During an observation of the room for Resident 2, Resident 3 and Resident 8, on 11/12/2020 at 1:20 p.m., there was no transmission signage noted immediately outside the residents' room. A