Health inspection·February 5, 2021

F880 §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. § 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. The facility failed to maintain an infection control program to prevent the spread of Coronavirus Disease 2019 (COVID-19, a highly contagious viral infection that spreads from person-to-person affecting the respiratory system and could result in death) by failing to ensure: 1. Kitchen Staff 3 (KS 3) used personal protective equipment (PPE - protective clothing, goggles, head/shoe covers, mask, gown, gloves or other garments or equipment designed to protect the wearer's body from infection) and performed hand hygiene before entering and exiting the Yellow Zone (designated area for residents under investigation [PUI] for potential exposure to COVID-19 infected people, pending laboratory test results, newly admitted and re-admitted residents). There was no signage indicating PPE required and reminders for hand hygiene by the doors communicating the facility next door (Facility 2, an assisted living facility) and the Yellow Zone, which was used by the dietary staff to deliver meals to the two facilities. 2. Ensure Licensed Vocational Nurse 2 (LVN 2) removed contaminated PPE and perform hand hygiene before leaving Resident 9’s room located in the Yellow Zone and before touching the medication cart and its content. 3. Ensure Staff 3, Staff 4, Staff 6 and Staff 7 wore N95 masks (or respirator, a particulate-filtering face piece that meets the U.S. National Institute for Occupational Safety and Health [NIOSH] and filters at least 95% of airborne particles and the edges of the respirator are designed to form a seal around the nose and mouth) without altering or modifying them. As a result, residents and staff were placed at an increased risk to be infected with COVID-19, becoming seriously ill, leading to hospitalization and/or death. 1. On 12/8/2020 at 2:13 p.m., during an observation of the Yellow Zone, KS 3 entered from Facility 2, next door, through a set of double doors that allow passage between the buildings and did not wash his hands or don PPE. KS 3 retrieved a meal cart from the hallway of the Yellow Zone, passed through the double doors again, leaving the facility and entering Facility 2 next door. There was a hand sanitizer dispenser near the double doors, KS 3 did not perform hand hygiene or wipe down the meal cart with a cleaning agent upon exiting. It was also noted there was no signage indicating the PPE required and to practice hand hygiene. There was no hand sanitizer or cart containing PPE near the double doors for staff to use when entering of leaving the facility through the double doors. During an interview, on 12/8/2020 at 2:46 p.m., the Administrator stated staff entering the Yellow Zone from Facility 2, next door, should be washing their hands or using hand sanitizer. The Administrator stated Facility 2 had an ongoing outbreak of COVID-19 amongst its residents and staff. The Administrator also stated his facility had a COVID-19 outbreak since 11/27/2020. 2. On 12/8/2020 at 2:21 p.m., during an observation of the Yellow Zone, LVN 2 put on PPE, entered Resident 9’s room, exited the room while still wearing PPE, and approached the medication cart in the hallway. LN 2 was observed handling items on the medication cart while still wearing gloves and other PPE, and then, returned to Resident 9’s room. On 12/8/2020 at 2:28 p.m., during an interview, LN 2 stated she should have removed her gloves and gown and either washed her hands or used hand sanitizer between leaving Resident 9’s room and touching the medication cart or items on the medication cart. 3. On 12/10/2020 at 3:45 p.m., Staff 3, 4, 6 and 7 were observed in the hallway of the Yellow Zone, wearing N95 masks with the elastic bands modified. On 12/10/2020 at 3:46 p.m., during an interview, Staff 3 stated she had cut the elastic bands of her N95 mask to make it more comfortable by retying the bands around her ears instead of having them behind her head and neck because, "It's easier to take on and off." On 12/10/2020 at 3:47 p.m., during an interview, Staff 4 stated she cut the elastic bands and retied the ends of the elastic bands because, "It's more comfortable." During an interview on 12/10/2020 at 3:48 p.m., Staff 6 stated he had cut the elastic bands of the mask so that he could retie them and loop them around his ears. During an interview on 12/10/2020 at 3:49 p.m., Staff 7 stated he had altered his N95 mask to make it more comfortable by securing it around his ears instead of around the back of his head and neck. On 12/17/20 at 3:19 p.m., during an interview, the Administrator stated he had reviewed the manufacturer's instructions for the use of the N95 mask and the masks should not be modified as the close fit around mouth and nose could be affected. On 12/17/20 at 3:21 p.m., during an interview, the Director of Nursing (DON) stated cutting the elastic bands of the N95 masks can result in a poor fit of the mask. A review of the website https://www.byd.care/products/n95-respirator, dated 2020, authored by the manufacturer of the N95 masks approved by the facility to be worn by facility staff while caring for residents, indicates, "Failure to properly use and maintain this product could result in injury or death. Never substitute, modify, add, or omit parts. A review of the website http://publichealth.lacounty.gov/acd/ncorona2019/covidcare/, authored by The Los Angeles County Department of Public Health, dated 10/28/2020, indicated older adults and people who have underlying medical conditions like heart or lung disease or diabetes are at higher risk for developing more serious complications from COVID-19. A review of the facility's policy and procedure titled "Hand Hygiene," dated 9/1/2012, indicated hand hygiene will be performed before donning and after doffing Personal Protective Equipment (PPE) and also immediately upon entering and exiting a resident room. A review of the facility's COVID-19 Mitigation Plan, dated 11/30/20, indicated "Cohorting Residents," Residents will be cohorted in one of three distinct areas of the facility; green, yellow or red. Residents who test negative for COVID-19 and have no signs or symptoms of the illness are kept in the GREEN area. Residents who are under investigation for COVID-19 are kept in the YELLOW area and those who are positive for COVID-19 are kept in the RED area. Additional Cohorting Requirements, Residents who tested positive for COVID-19 should be separated from all residents who test negative and all residents under investigation for COVID-19. The Mitigation Plan indicated all residents who test positive for COVID-19 should be in a single area within the facility, red area. The facility failed to maintain an infection control program to prevent the spread of Coronavirus Disease 2019 (COVID-19, a highly contagious viral infection that spreads from person-to-person affecting the respiratory system and could result in death) by failing to ensure: 1. Kitchen Staff 3 (KS 3) used PPE and performed hand hygiene before entering and exiting the Yellow Zone. There was no signage indicating PPE required and reminders for hand hygiene by the doors communicating the facility next door (Facility 2, an assisted living facility) and the Yellow Zone, which was used by the dietary staff to deliver meals to the two facilities. 2. Ensure Licensed Vocational Nurse 2 (LVN 2) removed contaminated PPE and perform hand hygiene before leaving Resident 9’s room located in the Yellow Zone and before touching the medication cart and its content. 3. Ensure Staff 3, Staff 4, Staff 6 and Staff 7 wore N95 masks without altering/modifying them. As a result, residents and staff were placed at an increased risk to be infected with COVID-19, becoming seriously ill, leading to hospitalization and/or death. The above violation had a direct or immediate relationship to the health, safety, and security of all residents and staff.