Health inspection·December 20, 2023

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. §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. § 72537. Reporting of Communicable Diseases. All cases of reportable communicable diseases shall be reported to the local health officer in accordance with Section 2500, Article 1, Subchapter 4, Chapter 4, Title 17, California Administrative Code. § 72539. Reporting of Outbreaks. Any outbreak or undue prevalence of infectious or parasitic disease or infestation shall be reported to the local health officer in accordance with Section 2502, Article 1, Subchapter 4, Chapter 4, Title 17, California Administrative Code. On 11/3/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint about infection control. The facility failed to immediately report an outbreak (more cases of a disease than expected in a specific location over a specific time period) of the communicable disease (an infection transmissible by direct contact with an affected individual or the individual's body fluids or by indirect means), Influenza (a highly contagious viral infection that attacks the respiratory system [throat, nose, and lungs]) for Resident 4, Resident 5, Resident 6, and Resident 7, to comply with state and local public health authority requirements. The facility failed to report the Influenza outbreak to CDPH Licensing and Certification [L&C] local District Office. As a result, there was a high risk of the spread of Influenza to all residents, staff, and visitors. 1. A review of Resident 4's Admission Record indicated the facility admitted Resident 4 on 5/4/2023 and re-admitted Resident 4 on 7/20/2023 with diagnoses including chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems). A review of Resident 4's laboratory report received by the facility on 11/1/2023 at 6:23 p.m., indicated that Influenza A & B (Influenza A can spread from animals to humans and Influenza B is also very contagious, but only spreads between humans) were detected. 2. A review of Resident 5's Admission Record indicated the facility admitted Resident 5 on 12/6/2022 with diagnoses including hemiplegia (a condition caused by brain damage that leads to paralysis [the loss of muscle function] on one side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infarction (damages to tissues in the brain due to a loss of oxygen to the area). A review of Resident 5's laboratory report received by the facility on 11/1/2023 at 6:23 p.m., indicated that Influenza A & B were detected. 3. A review of Resident 6's Admission Record indicated the facility admitted Resident 6 on 12/7/2022 with diagnoses including COPD. A review of Resident 6's laboratory report received by the facility on 11/1/2023 at 6:23 p.m., indicated that Influenza A & B were detected. 4. A review of Resident 7's Admission Record indicated the facility admitted Resident 7 on 4/17/2021 with diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). A review of Resident 7's laboratory report received by the facility on 11/1/2023 at 6:23 p.m., indicated that Influenza A & B were detected. During an interview with the Infection Preventionist (IP) on 11/6/2023 at 3:32 p.m., the IP stated the facility received the detection of Influenza test results for Residents 4, Resident 5, Resident 6, and Resident 7 on 11/1/2023 at around 7:28 p.m., and he reported the outbreak to the Local Health Department Public Health Nurse (PHN 1) the following day, 11/2/2023. PHN 1 instructed the IP to report the Influenza outbreak to the Acute Communicable Disease Center (ACDC) line. The IP called and reported to the ACDC line on 11/2/2023 at 2:32 p.m. The IP further stated that he did not know that the Influenza outbreaks should be reported to the local/state public health officials immediately. On 11/7/2023 at 11:10 a.m., during a concurrent interview with the Administrator (ADM), the Director of Nursing (DON), and the Director of Staff Development (DSD), the DSD stated the facility reported to PHN 1 and ACDC line the following day, 11/2/2023. The DSD further confirmed the facility did not report to the CDPH L&C local District Office. A review of the ACDC Reportable Diseases and Conditions for the Los Angeles Department of Public Health (LA DPH) last revised on 7/24/2023, indicated Influenza, due to novel (new) strains, is to be reported by telephone immediately for both confirmed and suspected cases. A review of the facility's policy and procedures titled, "Infection Outbreak Response and Investigation", revised 9/19/2023, indicated, "The facility promptly responds to outbreaks of infectious diseases within the facility to stop transmission of pathogens and prevent additional infections .... "Outbreak" generally refers to the occurrence of more cases of a communicable disease than expected in a given area or among a specific group of people over a particular period of time. If a condition is rare or has serious health implications, an outbreak may involve only one case .... An outbreak will be reported to the local and/or state health department in accordance with the state's reportable diseases website." The facility failed to immediately report an outbreak of the communicable disease, Influenza for Resident 4, Resident 5, Resident 6, and Resident 7, to comply with state and local public health authority requirements. The facility failed to report the Influenza outbreak to CDPH L&C local District Office. As a result, there was a high risk of the spread of Influenza to all residents, staff, and visitors. The above violation had a direct or immediate relationship to the health, safety, or security of all residents in the facility.