Other·January 16, 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)The facility must establish an infection prevention and control program (IPCP) 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 CFR §72537 Reporting of Communicable Diseases All cases of reportable communicable diseases shall be reported to the local health officer.    22 CFR §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 CFR §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 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 an organized fire service, to the State Fire Marshal.     22 CFR §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. On 12/01/2023, the Department received a complaint indicating four (4) positive residents’ cases of 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 12/06/2023, at 11:47 a.m., an unannounced visit was conducted at the facility to investigate the COVID-19 outbreak. The facility failed to: 1. Implement its policy and procedure titled, “Infection Prevention and Control Program” which indicated to report outbreak information to the 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 (Face Sheet) indicated Resident 1 was a 61-year-old male, admitted to the facility on 10/16/2023 with diagnoses including diabetes (high blood sugar), hypertension (high blood pressure), and heart failure (the heart is unable to pump blood around the body).? A review of Resident 1’s History and Physical (H&P), the H&P indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1’s Change of Condition ([COC] a clinical deviation from a resident's baseline) dated 12/01/2023, indicated Resident 1 tested positive for COVID-19. A review of Resident 1’s Test Results Final Report dated 12/04/2023, indicated Resident 1 Covid-19 was detected. During an interview on 12/06/2023 at 12:15 a.m. the Infection Preventionist (IP) stated there were five residents positive for COVID-19 in the facility. The IP stated their first case of COVID 19 positive resident was Resident 1, who tested positive on 12/01/2023. The IP stated the facility COVID -19 outbreak was not reported to the Department on 12/01/2023 because she was not aware that it needed to be reported. During an interview on 12/06/2023 at 4 p.m., the Administrator (ADM) stated the facility’s COVID -19 outbreak was not reported to the Department because he was not aware that it needed to be reported. A review of the facility’s policy and procedure (P&P) titled, “Infection Prevention and Control Program,” dated 2023, indicated outbreaks will be reported, should any resident(s) or staff suspected or diagnosed a reportable communicable/infectious disease, such information shall be promptly reported to appropriate local and/or state health department officials. The facility failed to: 1. Implement its policy and procedure titled, “Infection Prevention and Control Program” which indicated to report outbreak information to the 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. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.