Other·December 13, 2022

42 CFR § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. §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. On 9/21/2022, the California Department of Public Health conducted an unannounced investigation at the facility for a complaint related to Infection Control. The facility failed to maintain a system to prevent and control the transmission of COVID-19 (Coronavirus disease 2019 is an infectious disease caused by virus that can result in different symptoms from mild to severe respiratory illnesses and is spread during close contact and through the air from person to person) infection for Resident 1, 2, 3, 4, 5, 6, 7 and 8 by failing to ensure seven staff: -Housekeeper [HK] 1, -Occupational Therapy Aide [OTA], -Maintenance Director, -Laundry Worker [LW] 1, Licensed Vocational Nurse [LVN] 1, Certified Nursing Assistant [CNA] 1 and CNA 2 were fit tested (a test to verify that a respirator is both comfortable and provides the wearer with the expected protection) for their N95 mask (a respirator, a respiratory protective device designed to achieve a very close facial fit and provide efficient filtration of airborne particles). As a result, on 8/25/2022, the OTA tested positive for COVID-19 after not being fit tested, the facility had a COVID-19 Outbreak (when a disease or illness spreads rapidly among individuals in an area or population at the same time), and on 9/1, 9/8, and 9/9/2022, Residents 1 and 2, Residents 3, 4, 5, 6 and Residents 7 and 8 respectively, tested positive for COVID-19 (eight total residents). This placed all staff and residents in the facility at risk of being infected and becoming seriously ill, possibly leading to hospitalization and / or death. a.A review of the color-coded facility floor plan dated 8/24/2022, indicated that all 76 residents were in the green zone (space designated for residents not exposed to COVID-19). A review of the OTA’s laboratory result dated 8/25/2022, indicated she tested positive for COVID-19. A review of Resident 2’s admission record indicated the facility admitted the resident on 6/21/2022 with diagnoses including, high blood pressure, and muscle weakness. A review of the Minimum Data Set (MDS - an assessment and care screening tool) dated 6/27/2022 indicated Resident 2 was cognitively intact (had no trouble remembering, learning new things, or making decisions) and required extensive assistance with one person assist for bed mobility, dressing, eating and personal hygiene. According to a review of Resident 2’s nursing progress notes, dated 8/30 and 8/31/2022, the resident experienced fevers of 99.8 degrees Fahrenheit and 100.1 degrees Fahrenheit, respectively. Resident 2 received cooling measures. A review of Resident 2’s Physician's Order, dated 8/31/2022, indicated Resident 2 was to receive a stat (right away) chest x-ray for cough, administer Paxlovid (a medication used to treat COVID-19) one tablet one time a day until 9/6/2022 for COVID-19 and azithromycin (an antibiotic) 250 milligram (mg) tablet one time a day until 9/4/2022 for pneumonia (lung infection). A review of the results of Resident 2’s chest x-ray dated 8/31/2022 indicated the resident had pneumonia. A review of Resident 2’s laboratory result dated 9/1/2022 indicated the resident tested positive for COVID-19. According to a review of the COVID-19 Outbreak Notification Letter from the Los Angeles County Department of Public Health (LAC DPH), dated 9/2/2022, indicated the facility was experiencing a COVID-19 outbreak. A review of the Medication Administration Record (MAR) dated 8/2022 and 9/2022, indicated Resident 2 received supplemental oxygen of one liter (L) per minute from 8/31/2022 to 9/10/2022, when her oxygen saturation fell below 97%. A review of the facility line list dated 9/9/2022 indicated the OTA had close contact (being within six feet of another person for at least 15 minutes) with Resident 2 and Resident 6 on 8/23 and 8/24/2022. A review of the Center for Disease Control and Prevention (CDC) Guideline titled, “What to Do If You Were Exposed to COVID-19,” indicated one can develop COVID-19 up to ten days after being exposed (https://www.cdc.gov/coronavirus/2019-ncov/your-health/if-you-were-exposed.html). A review of Resident 6’s admission record indicated the facility readmitted the resident on 8/1/2022 with diagnoses including respiratory failure, atrial fibrillation and high blood pressure. According to a review of Resident 6’s MDS dated 8/1/2022, the resident’s cognition was severely impaired (trouble remembering, learning new things, or making decisions) and required one-person physical assist with toileting and personal hygiene. A review of Resident 6’s Change of Condition form dated 8/26/2022 indicated he was exposed to COVID-19 by staff (OTA). A review of Resident 6’s Interdisciplinary Team note dated 8/26/2022 indicated he was directly exposed to COVID-19, was being monitored for signs and symptoms of COVID-19 and would remain in the yellow zone (space designated to be occupied by residents potentially exposed to COVID-19). A review of the laboratory tests dated 9/8/2022, indicated Resident 6 tested positive for COVID-19. During an observation on 9/21/2022 at 1:53 PM of the personal protective equipment (PPE) storage area, the Maintenance Director was observed wearing a Honeywell TC-84A-8480 N95 mask. During a concurrent interview, the Maintenance Director stated he was not fit tested and was given his mask by the facility. During an observation and concurrent interview on 9/21/2022 at 2:25 PM, Housekeeper (HK1) was observed wearing a Honeywell TC-84A-8480 N95 mask. HK1 stated she was not fit tested for this mask and, “I got it from the front desk (facility reception area).” HK1 stated she worked in the yellow and red zones (space designated specifically for COVID-19 positive residents). During an interview on 9/21/2022 at 2:48 PM and concurrent review of the facility’s N95 fit test log, the Infection Preventionist (IP) stated she could not find any fit testing documentation for HK1, the Maintenance Director, or Licensed Vocational Nurse (LVN) 1. During an interview on 9/21/2022 at 2:57 PM, LVN 1 stated she had not been fit tested for a N95 respiratory mask. During an interview on 10/6/2022 at 2:40 PM, the IP stated she could not provide fit testing documentation for the OTA, Laundry Worker and CNA1 or CNA2. She stated that all staff were to be N95 tested yearly, or upon hire. The IP stated N95 masks protect us and others from COVID-19 and other airborne viruses. b. A review of Resident 1’s admission record indicated the facility admitted Resident 1 on 4/28/2022 with diagnoses including dementia (loss of memory, thinking and reasoning) and hypothyroidism (a condition where the thyroid gland does not produce enough hormone). A review of Resident 1’s MDS dated 8/4/2022, indicated the resident had moderately impaired cognition (decisions poor, cues/supervision required), and required extensive assistance with one person assist for personal hygiene, dressing, bed mobility, transfer, and toilet use. A review of the laboratory test dated 9/1/2022 indicated Resident 1 tested positive for COVID-19. A review of the social services note dated 9/1/2022, indicated Resident 1 was moved to the red zone. A review of Resident 3’s admission record indicated the facility admitted the resident on 5/9/2022 with diagnoses including peripheral vascular disease (PVD -a slow and progressive circulation disorder) and chronic kidney disease (kidneys are damaged and unable to filter blood the way they should). A review of Resident 3’s IDT note dated 8/28/2022 indicated Resident 3 was placed in the yellow zone for exposure from a COVID-19 positive staff member working at the facility from 8/23/2022 to 8/24/2022. A review of Resident 3’s change in condition (COC) form dated 9/8/2022 indicated Resident 3 tested positive for COVID-19 and complained of a sore throat. A review of Resident 4’s admission record indicated the facility admitted the resident on 6/21/2022 with diagnoses including emphysema (a lung condition that causes shortness of breath), heart failure and Type II diabetes (impairment in the way the body regulates and uses sugar [glucose] as a fuel, high blood sugar). A review of the COC form dated 9/8/2022 indicated Resident 4 tested positive for COVID-19 on 9/7/2022. A review of Resident 5’s admission record indicated the facility re-admitted the resident on 11/20/2020 with diagnoses including protein calorie malnutrition (a condition where one does not consume enough to meet their nutritional needs which can lead to a weak immune system) and atherosclerotic heart disease (a buildup of fats, cholesterol and other substances that decreases blood flow to the heart). A review of the MDS dated 8/20/2022 indicated Resident 5’s cognition was mildly impaired and required extensive assistance with one person assist for personal hygiene, dressing, bed mobility, transfer, and toilet use. A review of the facility census dated 9/7/2022 indicated Residents 5, 7, and 8 shared a room. A review of COC dated 9/8/2022 indicated Resident 5 tested positive for COVID-19. A review of Resident 7’s admission record indicated the facility re-admitted the resident on 7/5/2017 with the diagnoses including pancreatic cancer, Type II diabetes, and protein calorie malnutrition. A review of Resident 7’s MDS dated 8/21/2022 indicated the resident had moderately impaired cognition and required extensive assistance with one person assist for dressing, bed mobility, personal hygiene, and toilet use. A review of Resident 7’s IDT note dated 8/28/2022 indicated Resident 7 was exposed to a COVID-19 positive staff member working at the facility from 8/23/2022 and 8/24/2022 and that the resident would remain in isolation (in the yellow zone) for 14 days. A review of Residents 7 and 8 COVID-19 laboratory tests dated 9/9/2022 indicated the tests were positive. A review of Resident 8’s admission record indicated the resident was readmitted to the facility on 5/23/2022 with diagnoses including shortness of breath, paranoid schizophrenia (a severe mental illness) and benign prostatic hyperplasia (enlargement of the prostate). A review of Resident 8’s MDS dated 6/14/2022 indicated the resident had moderately impaired cognition and required extensive assistance with one person assist for dressing, bed mobility, personal hygiene, and toilet use. A review of Resident 8’s IDT note dated 8/28/2022 indicated Resident 8 was in isolation due to exposure from a COVID-19 positive staff working at the facility from 8/23/2022 to 8/24/2022, would be monitored for symptoms of COVID-19 and will continue with isolation for 14 days. During a phone interview with the facility’s Medical Director on 10/27/2022 at 10:35 AM, when asked about the importance of fit testing, he stated, “This is the first time I am hearing of fit testing. It’s not uniform in every facility or hospital. I am completely unaware that this is a mandatory test. I go there (to the facility) and they give me a mask, I was never tested.” A review of the Center for Disease Control and Prevention (CDC) guideline titled, “The Respiratory Protection Information Trusted Source,” revised 9/3/2021, indicated users were required to be fit tested to confirm the fit of any respirator that forms a tight seal on your face before using it in the workplace. Fit testing was important to ensure the expected level of protection was provided by minimizing the total amount of contaminant leakage into the facepiece through the seal. It also indicated that one should be fit tested yearly to ensure that N95 mask fits properly (https://www.cdc.gov/niosh/npptl/topics/respirators/disp_part/respsource3fittest.html#:~:text=You%20should%20be%20fit%20tested,type%2Fbrand%2C%20or%20size). A review of the facility’s policy and procedure titled, “Coronavirus (COVID-19) - Infection Prevention and Control Measures, revised July 2020, indicated that while in the building, personnel were required to strictly adhere to established infection prevention and control policies including appropriate use of PPE. A review of the facility’s policy and procedure titled, “Coronavirus Disease 2019 (COVID-19) Mitigation Plan for Skilled Nursing Facilities,” undated, indicated that facility staff were fit tested for N95 masks. The facility failed to maintain a system to prevent and control the transmission of COVID-19 (Coronavirus disease 2019 is an infectious disease caused by virus that can result in different symptoms from mild to severe respiratory illnesses and is spread during close contact and through the air from person to person) infection for Resident 1, 2, 3, 4, 5, 6, 7 and 8 by failing to ensure seven staff: -Housekeeper [HK] 1, -Occupational Therapy Aide [OTA], -Maintenance Director, -Laundry Worker [LW] 1, Licensed Vocational Nurse [LVN] 1, Certified Nursing Assistant [CNA] 1 and CNA 2 were fit tested (a test to verify that a respirator is both comfortable and provides the wearer with the expected protection) for their N95 mask (a respirator, a respiratory protective device designed to achieve a very close facial fit and provide efficient filtration of airborne particles). As a result, on 8/25/2022, the OTA tested positive for COVID-19 after not being fit tested, the facility had a COVID-19 Outbreak (when a disease or illness spreads rapidly among individuals in an area or population at the same time), and on 9/1, 9/8, and 9/9/2022, Residents 1 and 2, Residents 3, 4, 5, 6 and Residents 7 and 8 respectively, tested positive for COVID-19 (eight total residents). This placed