Health inspection·September 4, 2024

California Code of Regulations, Title 22, Section § 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. Code of Federal Regulations, Title 42 F880- 483.80 Infection Prevention & Control 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. The facility failed to ensure that outbreaks of communicable disease are identified and reported to the California Department of Public Health (CDPH) and local public health officer, in accordance with the facility ' s policy and procedure on "Communicable Diseases - Outbreak." The facility failed to report a Coronavirus 2019 (COVID- 19, an infectious disease) Outbreak to CDPH within 24 hours of occurrence for Patients 1, 2, 3, 4, and 5 who tested positive for COVID-19 As a result, the California Department of Public Health was not aware of the outbreak and delayed timely on-site investigation to ensure the facility was taking proper precautions to ensure the welfare and safety of the patients and staff during this outbreak. This deficient practice had the potential to result in unidentified, uncontrolled COVID-19 infection to facility’s patients. a. A review of Patient 1’s admission record indicated the patient, 68 years old male was admitted to the facility on 7/5/2024, with diagnoses that included Hemiplegia (cannot move muscles) and hemiparesis (weakness on one side of body) following cerebral infarction (an interruption in the flow of blood to cells in the brain). A review of Patient 1 ' s history and physical (H&P) dated 7/7/2024, indicated the patient did not have the capacity to understand and make decisions. A review of Patient 1 's rapid antigen test (antigen tests look for the presence of one or more proteins that are part of the virus that causes COVID-19) on 1/15/2024 indicated Patient 1 tested positive for COVID-19. b. A review of Patient 2’s admission record indicated the patient, a 92 years old male with diagnoses that indicated, Chronic obstructive pulmonary disease (common lung disease that causes airflow and breathing problems). A review of Patient 2’s H&P dated 12/18/2023, indicated the patient does not have the capacity to understand and make decisions. A review of Patient 2 ' s rapid antigen test for COVID-19 dated 1/15/2024, indicated the patient tested positive for COVID-19. c. A review of Patient 3’s admission record indicated the patient, a 62 years old male was admitted to the facility on 2/2/2024 with diagnoses that indicated muscle wasting (the weakening, shrinking, and loss of muscle) and atrophy (the loss of skeletal muscle mass). A review of Patient 3’s H&P dated 2/12/2024, indicated the patient has the capacity to understand and make decisions. A review of Patient 3 ' s rapid antigen test for COVID-19 dated 1/15/2024, indicated the patient tested positive for COVID-19. d. A review of Patient 4’s admission record indicated, a 79 years old male originally admitted to the facility on 10/02/2023 and readmitted on 7/15/2024 with a diagnosis of COVID-19. A review of Patient 4 ' s H&P dated 7/29/2024, indicated the patient does not have the capacity to understand and make decisions. A review of Patient 4 ' s Progress notes dated 7/10/2024, indicated the patient was transferred to General Acute Care Hospital 1 for COVID-19 on 7/10/2024 at 1:20 pm. A review of Patient 4 ' s GACH 1 record dated 7/13/2024, the patient tested positive for COVID-19 on 7/12/2024. A review of Patient 4 ' s progress notes dated 7/15/2024, indicated the patient returned to the facility from GACH 1. e. A review of Patient 5’s admission record indicated a 89 years old female admitted to the facility on 6/20/2024, with diagnosis that included right fracture of the femur (break or crack in the thigh bone). A review of Patient 5 ' s H&P dated 6/21/2024, indicated the patient does not have the capacity to understand and make decisions. A review of Patient 5 ' s progress notes dated 7/15/2024, indicated the patient tested positive for COVID-19. During an interview on 7/23/2024 at 10:15 am with the IP, the IP stated Patient 5 tested positive for COVID 19 on 7/15/2024 and left facility against medical advice on same day (7/15/2024). During an interview with the Infection preventionist (IP), on 7/23/2024 at 10:15AM, the IP stated Patient 5 was transferred to the GACH on 7/10/2024. On 7/12/2024, the GACH called the facility and was notified that Patient 5 tested positive for COVID-19. IP stated mass testing (regular screening test to the general population) was initiated on 7/15/2024. The mass testing resulted with a total of five (5) patients testing positive for COVID-19. The IP stated that as of today, 7/23/20224, there were a total of seven (7) patients who have tested positive for COVID-19. The IP stated she did not report the COVID-19 outbreak to CDPH. During an interview on 7/23/2024 at 3:02 pm with the DON, the DON stated if an outbreak occurs, the facility should notify CDPH. A review of the facility ' s policy and procedure (P&P) titled, "Communicable Diseases - Outbreak" revised 3/6/2024, indicated facility was to ensure that outbreaks of communicable disease are identified, handled, and reported as required. Procedures for contact tracing between the infected individuals and other residents and staff are initiated. Symptomatic residents and employees are to be considered potentially infected and are assessed for appropriate action and the administrator will be responsible for: Reporting to CDPH and local public health officer. The facility failed to ensure that outbreaks of communicable disease are identified and reported to the California Department of Public Health (CDPH) and local public health officer, in accordance with the facility ' s policy and procedure on "Communicable Diseases - Outbreak." The facility failed to report a Coronavirus 2019 (COVID- 19, an infectious disease) Outbreak to CDPH within 24 hours of occurrence for Patients 1, 2, 3, 4, and 5 who tested positive for COVID-19 As a result, the California Department of Public Health was not aware of the outbreak and delayed timely on-site investigation to ensure the facility was taking proper precautions to ensure the welfare and safety of the patients and staff during this outbreak. This deficient practice had the potential to result in unidentified, uncontrolled COVID-19 infection to facility’s patients. The above violations had a direct or immediate relationship to the health, safety or security of Patients 1, 2, 3, 4, 5 and patients residing in the facility.