Other·December 11, 2023

22 CCR §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. 22 CCR § 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. 22 CCR § 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 11/22/2023, 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 a disease when on 11/20/2023 seven residents experienced gastrointestinal (GI, relating to the stomach and intestines) symptoms such as nausea, vomiting, and diarrhea to the local Department of Public Health (DPH) to comply with state and local public health authority requirements. By the next day, 11/21/2023, there were a total of 21 residents with similar GI symptoms. As a result, there was a high risk of the spread the GI illness to all 186 residents, staff, and visitors. During an interview with the Director of Nursing (DON), Infection Preventionist Nurse (IPN) and Administrator (ADM) on 11/22/2023 at 1:45 p.m., the IPN stated that on 11/20/2023, a total of seven residents manifested symptoms of nausea, vomiting and diarrhea and the next day, 14 more residents were experiencing nausea, vomiting and diarrhea. The IPN stated that on 11/21/2023, the residents with GI symptoms got quarantined (separated from others for a specific time period to prevent the spread of infection) at the East and South side of the facility. The IPN stated the facility staff was still investigating the cause of the GI symptoms, but it was not identified yet. A review of the undated log titled, “Infection Control Activity Log,” indicated that on 11/20/2023, seven residents had GI symptoms such as nausea, vomiting and/or diarrhea. Nursing staff notified each resident’s Medical Doctor (MD), conducted antigen testing and placed all the residents experiencing GI related symptoms on contact precaution (steps such as handwashing, putting gloves and gown on and off to prevent spread of infection). On 11/21/2023, there were 14 more residents who experienced GI symptoms. The IPN notified the MD, initiated care plans, and placed all the residents to contact precautions. There was no documentation the local DPH had been notified by telephone immediately on 11/20/2023 as indicated in the Los Angeles County DPH Reportable Diseases and Conditions revised on 7/24/2023. During a phone interview with the ADM on 11/27/2023 at 1:26 p.m., ADM stated that he instructed his DON to report the outbreak to the local health department; however, he could not confirm it was done. During a phone interview with the ADM on 11/28/2923 at 3:39 p.m., ADM indicated the IPN did not report the incident to the local Public Health Department. A review of the facility’s policy and procedures (P&P) titled, “Unusual Occurrence,” revised on 12/06/2022, indicated, “Occurrences such as epidemic outbreaks, poisoning, 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. (5) Notify by telephone or fax the following parties: Physician, Conservator, Family, Department of Health and Services, Department of Mental Health, Fire and/or Police Department, if necessary.” The facility failed to immediately report an outbreak of a disease when on 11/20/2023 seven residents experienced GI symptoms such as nausea, vomiting, and diarrhea to the local DPH to comply with state and local public health authority requirements. By the next day, 11/21/2023, there were a total of 21 residents with similar GI symptoms. As a result, there was a high risk of the spread the GI illness to all 186 residents, staff, and visitors. The above violations had a direct or immediate relationship to the health, safety, or security of all residents in the facility.