Health inspection·August 19, 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. 22 CFR § 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 CFR § 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 CFR § 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 6/28/2024, the California Department of Public Health (CDPH) received a complaint alleging the Director of Nursing (DON) was not reporting positive cases of the corona virus ([Covid-19] an acute disease caused by a coronavirus, capable of progressing to severe symptoms, including death, especially in older people and those with underlying health conditions) to the local health department. On 7/10/2024 at 8:05 AM, an unannounced visit was conducted at the facility to investigate the allegation. The facility failed to: 1. Report three new cases of Covid-19 to the local health department on 6/21/2024 and 6/24/2024 (Laundry Staff [LS] 1, Licensed Vocational Nurse [LVN] 1, and Resident 5), prior to closing an outbreak (the occurrence of more cases of disease than expected in a given area or among a specific group of people over a particular period of time) at the facility. As a result, facility residents, staff and the community were placed at risk for Covid-19 infection, illness and/or death. 1. During a concurrent interview and record review, on 7/10/2024 at 10:20 AM, with the DON, the facility's untitled and undated line list (a table containing key information about an outbreak) was reviewed. The DON stated there were two Covid-19 positive staff cases on 6/21/2024 (LS 1 and LVN 1) and one positive resident case (Resident 5 in Room A) on 6/24/2024. The DON stated all positive cases had been reported to the local health department. During an interview on 7/10/2024 at 10:37 AM with the facility's assigned Public Health Nurse (PHN) 1, PHN 1 stated the facility had an active Covid-19 outbreak from 6/11/2024 to 6/24/2024. PHN 1 stated the facility did not report the positive staff cases on 6/21/2024, or the positive resident case on 6/24/2024. PHN 1 stated the outbreak would have been extended beyond 6/24/2024 if the facility had notified her of the three new positive cases. PHN 1 stated the facility was supposed to report all positive cases during an outbreak in the facility. PHN 1 stated failure to report positive cases created the risk for transmission to vulnerable residents, visitors, and staff. PHN 1 stated Covid-19 was a high-risk infection and should be reported immediately. During an interview on 7/10/2024 at 3:08 PM with PHN 1, PHN 1 stated the outbreak clearance letter (a letter indicating the conclusion of the outbreak) was sent to the facility on 6/24/2024 at 4:19 PM. PHN 1 stated the facility should have tested Resident 6 on 6/24/2024, 6/29/2024, and 7/4/2024 after identifying Resident 5 (Resident 6's roommate) was positive for Covid-19. During an interview on 7/11/2024 at 10:24 AM, with LVN 1, LVN 1 stated their last day of work prior to testing positive for Covid-19 was 6/19/2024. LVN 1 stated she tested positive on 6/20/2024, and stated the DON was notified via text message on 6/20/2024 of the positive Covid-19 test result. During a concurrent interview and record review, on 7/11/2024 at 11:01 AM, with the DON, Resident 5's Change of Condition Evaluation (COC), dated 6/24/2024, was reviewed. The DON stated the COC indicated Resident 5's difficulty breathing was reported to the Charge Nurse at 12:26 PM on 6/24/2024. The DON stated difficulty breathing was considered a symptom of Covid-19 and should have been reported to PHN 1. The DON also stated residents with symptoms were supposed to be tested for Covid-19. The DON stated there was no documentation in Resident 5's medical record to indicate the resident was tested once her difficulty breathing was identified at 12:26 PM. The DON stated Resident 5 was transferred to general acute care hospital [BF2] (GACH) 1 on 6/24/2024 and stated FM 2 notified him at 4:05 PM that Resident 5 tested positive for Covid-19 upon arrival to GACH 1. The DON stated he was aware Resident 5's positive Covid-19 result and did not report it to PHN 1 prior to PHN 1's closure of the Covid-19 outbreak. The DON stated he should have reported the positive result and stated failing to report the positive result put other facility residents and staff at risk. During a concurrent interview and record review, on 7/11/2024 at 1:37 PM, with the ADM, the facility's P&Ps titled "Coronavirus Disease (Covid-19) Updated Policy on Surveillance, Testing, Reporting and Staffing Guidance", dated 10/7/2022, and "Coronavirus Disease (Covid-19) Infection Prevention and Control Measures, dated 7/2020, were reviewed. The ADM stated these P&Ps were the current P&Ps followed in the facility for Covid-19. The ADM stated the P&Ps were not currently under review or in the process of being revised. During a concurrent interview and record review, on 7/11/2024 at 2:35 PM, with the DON, the Health Officer Orders (HOO) sent to the facility by PHN 1, dated 6/11/2024, was reviewed. The DON stated the two positive staff cases on 6/21/2024 and positive resident case on 6/24/2024 were not reported, and stated the HOO indicated all positive cases were supposed to be reported. The DON stated failure to report the positive cases and failure to perform the required testing created the risk for a worsening of the Covid-19 outbreak, and for more residents and staff to be infected by Covid-19. During an interview on 7/11/2024 at 4:00 PM, with the ADM and DON, the ADM stated LVN 1's positive Covid-19 result was not reported because they did not believe the positive result was real. The DON stated LS 1's positive Covid-19 result was not reported because LS 1 was "on vacation" before testing positive. The DON stated the HOO provided at the beginning of the outbreak did not indicate it was at the facility's discretion to decide which positive results to report. 2. A review of Resident 5's Admission Record indicated Resident 5, a 79-year-old female, was admitted to the facility on 5/16/2024, and most recently re-admitted on 7/6/2024. Resident 5's admitting diagnoses included heart failure (when the heart muscle doesn't pump blood as well as it should), systemic lupus erythematosus (a disease where the immune system of the body mistakenly attacks healthy tissue), and asthma (a chronic lung disease affecting people of all ages), and respiratory failure (condition in which your blood doesn't have enough oxygen or has too much carbon dioxide). A review of Resident 5's MDS, dated 6/24/2024, indicated Resident 5 had impaired short-term memory (ability to recall events from the last 5 minutes) and mild cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 5 did not display any rejection of care, and indicated she required substantial to maximal assistance from staff for eating, brushing her teeth, and getting dressed. The MDS indicated Resident 5 also needed substantial to maximal assistance from staff to reposition herself from left to right while in bed, and to move from a lying to a sitting position. The MDS further indicated that in the 14 days prior to the MDS assessment, and while residing in the facility, Resident 5 did not require oxygen therapy. A review of Resident 5's COC, dated 6/24/2024, indicated Resident 5 had trouble breathing on 6/24/2024 at 12:26 PM and had an oxygen saturation (amount of oxygen in the blood) of 90% (normal range is between 95% and 100%) while on two (2) L/min of oxygen through a nasal cannula. The COC indicated the Charge Nurse placed Resident 5 into an upright position and increased the oxygen delivery rate to 3 L/min. The COC indicated that at 1:35 PM, Resident 5 reported feeling increasingly short of breath, and her heart rate and blood pressure were elevated and outside of normal range. The COC indicated the Charge Nurse called 911 (emergency services) to transfer patient to a GACH. A review of Resident 5's progress note, dated 6/24/2024, indicated Resident 5 was picked up by paramedics and transferred to GACH 1. A review of Resident 5's records from GACH 1, dated 6/25/2024, indicated Resident 5 was admitted to GACH 1 on 6/24/2024 and the emergency department determined she was positive for Covid-19, and suffering from acute respiratory distress (a condition where the body needs more oxygen), pneumonia (an infection in your lungs caused by bacteria, viruses or fungi), and sepsis (a life-threatening complication in which the body responds improperly to an infection) due to Covid-19. The GACH 1 records also indicated Resident 5 received remdesivir (a medication used to treat Covid-19) during her GACH 1 admission. A review of the facility P&P titled "Coronavirus Disease (Covid-19) Updated Policy on Surveillance, Testing, Reporting and Staffing Guidance", dated 10/7/2022, indicated "the health department is notified of any resident with suspected or confirmed Covid-19, severe respiratory infection, or a cluster (3 or more residents or staff with new onset respiratory symptoms over 72 hours). The P&P indicated for routine diagnostic testing, in response to a positive test, "testing will continue to be performed to resident and staff with higher-risk exposures or close contact to Covid19 (i.e., as part of response testing)", and indicated "the Infection Preventionist will contact the local and/or state health departments to coordinate care as indicated". The P&P indicated for response driven testing, staff and residents should be tested "promptly" and the facility will contact Public Health Office for further guidance. The P&P indicated "newly admitted...regardless of vaccination status, should have a series of three viral tests for SARS-COV-2 infection: immediately upon admission and if negative, again at 3 days and 5 days after their admission or return to facility". The facility failed to: 1. Report three new cases of Covid-19 to the local health department on 6/21/2024 and 6/24/2024 (Laundry Staff [LS] 1, Licensed Vocational Nurse [LVN] 1, and Resident 5), prior to closing an outbreak (the occurrence of more cases of disease than expected in a given area or among a specific group of people over a particular period of time) at the facility. As a result, facility residents, staff and the community were placed at risk for Covid-19 infection, illness and/or death. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.