Other·January 30, 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) 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: (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. (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. 22CCR § 72321. Nursing Service -Patients with Infectious Diseases. (a) Patients with infectious diseases shall not be admitted to or cared for in the facility unless the following requirements are met: (1) A patient suspected of or diagnosed as having an infectious or reportable communicable disease or being in a carrier state who the attending officer determines is a potential danger, shall be accommodated in a room, vented to the outside, and provided with a separate toilet, hand-washing facility, soap dispenser and individual towels. (b) The facility shall adopt, observe, and implement written infection control policies and procedures. These policies and procedures shall be reviewed at least annually and revised as necessary. 22CCR §72523- Patient Care Policies and Procedures (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. (c) Each facility shall establish and implement policies and procedures, including but not limited to: (3) Infection control policies and procedures. 22CCR §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. On 1/3/2024, the California Department of Public Health (CDPH) received a complaint indicating the facility’s failure to perform infection control practices to prevent the spread of the Coronavirus Disease ([COVID-19] a highly contagious infection caused by a virus that could easily spread from person to person) and the failure to report COVID-19 outbreak (at least one confirmed COVID-19 case in the facility for at least 7 days). On 1/4/2024, at 11:30 a.m., the CDPH conducted an unannounced investigation at the facility. The facility failed to: 1) Implement the All Facilities Letter (AFL, a letter to all nursing facilities regarding new changes or updates) 23-09, dated 1/18/2023, which indicated to report COVID-19 outbreak to the CDPH. As a result there was a delay in the investigation by the State agency (CDPH). 1) A review of Resident 1’s admission record (face sheet) indicated Resident 1 was a 58-year-old male, admitted to the facility on 7/29/2023, with a diagnosis including diabetes (abnormal blood sugar), metabolic encephalopathy (brain problem ), and muscle weakness. A review of Resident 1’s history and physical (H&P) dated 9/9/2023 indicated Resident 1 did not have the capacity to understand and make medical decisions. A review of the facility’s undated resident line listing (spreadsheet to keep track of COVID-19 positive residents) indicated Resident 1 tested positive for COVID-19 on 1/1/2024. A review of Resident 1's Licensed Nursing note dated 1/1/2024, at 12:30 p.m. indicated Resident 1 had a positive COVID-19 antigen result. 2) A review of Resident 2’s face sheet indicated Resident 2 was a 74-year-old male, admitted to the facility on 10/12/2022, with a diagnosis that including hepatitis C (a virus that attacks the liver), asthma (inflamed airways of the lung), and hypertension (high blood pressure). A review of Resident 2’s H&P dated 1/4/2024, indicated Resident 2 had the capacity to understand and make medical decisions. A review of the facility’s undated resident line listing indicated Resident 2 tested positive for Covid-19 on 1/1/2024. A review of Resident 2’s Administration notes dated 1/1/2024 indicated Resident 2 was transferred to a different room due to COVID-19. 3) A review of Resident 3’s face sheet indicated Resident 3 was a 47-year-old male, admitted to the facility on 7/31/2019, with a diagnosis including anoxic brain damage (lack of oxygen to the brain), anxiety disorder (persistent and excessive worry that interferes with daily activities), and hypertension. A review of Resident 3’s H&P dated 1/4/2024 indicated Resident 3 did not have the capacity to understand and make medical decisions. A review of the facility’s undated resident line listing indicated Resident 3 tested positive for COVID-19 on 1/5/2024. A review of Resident 3's Administration notes dated 1/1/2024 at 4 p.m., indicated Resident 3 was moved to a different station due to positive COVID-19 test result. 4) A review of Resident 4’s face sheet indicated Resident 4 was a 69-year-old female, admitted to the facility on 2/25/2023, with diagnosis including multiple sclerosis (a condition that can affect the brain and cause symptoms such as with vision, arm or leg movement, sensation or balance problem), depression (loss of pleasure or interest in activities for long periods of time) and hypertension. A review of the facility’s undated resident line listing indicated Resident 4 tested positive for COVID-19 on 12/29/2023. During an interview on 1/8/2024 at 9:00 a.m., with the Infection Prevention (IP) nurse 1, IP nurse 1 stated she was assigned to assist IP nurse 2 and she was not aware the COVID-19 outbreak needed to be reported to CDPH. IP nurse 1 stated she came back to the position to assist during the outbreak and was not made aware of the new changes in the AFL 23-09. During an interview on 1/8/2024 at 11:00 a.m., with IP 2, IP 2 stated she was not aware of the new changes in the AFL 23-09 requiring the facility to report COVID-19 positive cases to their local district office. IP 2 stated she only reported the outbreak to the local health department. A review of the California Department of Public Health AFL 23-9 dated 1/18/2023 indicated all licensed health facilities should to report outbreaks and unusual infectious disease occurrences to the local health department and license and certification district office. The facility failed to: 1. Report COVID-19 outbreak to the CDPH as indicated in the All Facilities Letter (AFL, a letter to all nursing facilities informing of new changes or updates) 23-09, dated 1/18/2023. 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. As a result, there was a delay in the investigation by the State agency. This violation had a direct or immediate relationship to the health, safety, or security of residents.