Health inspection·March 9, 2023

F880 §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. § 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. § 72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan, which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. On 1/18/2023, the Department received an anonymous complaint regarding allegations of improper infection control practices. On 1/19/2023, an unannounced investigation was conducted at the facility. The facility failed to:  a. Ensure Resident 1, who was exhibiting symptoms of suspected scabies (a contagious, intensely itchy skin condition caused by a tiny, burrowing mite), was provided with necessary care and treatment including reassessing and providing an update to Resident 1’s physician, placed on contact precautions (intended to prevent transmission of infectious agents) and implement infection and prevention protocols. b. Perform skin scrapings (a test to confirm or rule out scabies) for Resident 1 who was exhibiting symptoms of suspected scabies, prior to being treated with Ivermectin (an antiparasitic drug, used to treat scabies) on 1/19/2023. c. Monitor for effectiveness of treatment of Resident 1 when treated with tea tree oil (used to treat acne, athlete's foot, lice, nail fungus and insect bites) and A&D ointment (used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations) in November 2022, December 2022, and January 2023.  d. Ensure the Infection Preventionist Nurse (IPN) followed the facility’s policies and procedures titled, “Scabies,” when facility staff, Rehabilitation Staff (RS) 1, RS 2, Certified Nurse Assistant (CNA) 3 and CNA 4, reported having suspected scabies, and were treated with Permethrin ordered by the staff’s private physicians.  d. Ensure proper infection surveillance (close observation or monitoring) of all residents and staff with suspected scabies by completing a line listing (a table that contains key information about each case in an outbreak [a sudden increase in the incidence of a disease or medical condition in a particular place or population]).  e. Report an outbreak of scabies to the local Health Department.   f. Adhere to the facility’s policy and procedure titled, “Scabies,” which stipulates to place all residents and staff suspected of scabies in contact precaution to prevent the spread of the infection.  As a result, Resident 1, continued to have itchy rashes on his trunk, arms, hands, and legs with no relieved from medication for two months. During a review of Resident 1’s Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was a 67-year-old male, was initially admitted to the facility on 8/4/2020 and last re-admitted on 12/9/2022. Resident 1’s diagnoses included diabetes mellitus (a group of diseases that result in too much sugar in the blood), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), hyperlipidemia (a condition in which there are high levels of fat particles called lipids in the blood), hypertension (high blood pressure), and unspecified dermatitis (a group of conditions in which the skin becomes inflamed, forms blisters, and becomes crusty, thick, and scaly).  During a review of Resident 1’s Minimum Data Set (MDS), an assessment and care screening tool, dated 12/16/2022, the MDS indicated Resident 1 had severely impaired cognitive skills for daily decision making (ability to reason and think), and required limited assistance with transfers, dressing, toileting, personal hygiene, and bathing. The MDS indicated Resident 1 did not have any skin problems.  During a review of Resident 1’s Progress Note dated 12/9/2022, the note indicated Resident 1 had scattered scratches to the face and widespread red dots noted to the body.  During a review of Resident 1’s Physician’s Order dated 12/9/2023, the order indicated to apply tea tree oil and A&D ointment from the neck to the feet twice a day for one month. The order was renewed on 1/10/2023 for unresolved unspecified dermatitis.  During a review of Resident 1’s Treatment Administration Record (TAR) for the months of November 2022, December 2022 and January 2023, the TARs indicated Resident 1 was treated with tea tree oil and A&D ointment for unspecified dermatitis. There was no monitoring of effectiveness of the treatment noted.  During a review of Resident 1’s care plan titled, “Unspecified Dermatitis,” dated 12/9/2022, the care plan indicated the resident’s goal was for the rash to resolve in one month. The staff’s interventions indicated to keep Resident 1 clean and dry, apply treatment as ordered, notify the physician if treatment was ineffective, and keep nails trim and short.  During a review of Resident 1’s Physician’s Telephone Order, on 1/18/2023, the order indicated to give Ivermectin 15 milligram (mg, unit of measurement) by mouth, one time dose for widespread dermatitis. The order was signed by the licensed nurse, however there was no physician signature noted.   During a review of Resident 1’s Medication Administration Record (MAR) for the month of January 2023, the MAR indicated on 1/18/2023, Resident 1 was given Ivermectin 15 mg by mouth.  During a concurrent observation and interview on 1/19/2023 at 10 a.m. with Resident 1, in Resident 1’s room, Resident 1 was observed lying on the bed scratching his neck with long fingernails. Resident 1 had three linear, deep scratch marks measuring approximately three inches long across his face. Resident 1 had multiple red skin rashes on his neck, trunk, arms, hands, and legs. Resident 1 stated he was very itchy at times.  During an interview with Certified Nurse Assistant (CNA) 1 on 1/19/2023 at 10:10 a.m., CNA 1 stated Resident 1 always complained of itchiness all over the body. CNA 1 stated she had been applying A&D ointment after the resident’s showers, but the ointment did not work because Resident 1 still had rashes.  During a concurrent interview and record review of Resident 1’s MAR and TAR for the month of November 2022, December 2022, and January 2023, on 1/19/2023 at 10:14 a.m., with Treatment Nurse (TN) 1, TN 1 stated Resident 1 was treated with tea tree oil and A&D ointment every day, however there was no daily monitoring for treatment effectiveness. TN 1 stated the Wound Consultant Physician Assistant (WCPA) visited every week to check the residents. TN 1 stated the Dermatologist visited every month. TN 1 stated she used an N95 respirator mask and gloves during Resident 1’s wound treatment. TN 1 stated there were no residents placed on contact precautions in the facility.  During an interview with Licensed Vocational Nurse (LVN) 1 on 1/19/2022 at 1:45 p.m., LVN 1 stated Resident 1 was being monitored by the WCPA because of suspicious rashes. LVN 1 stated the resident’s physician was aware of the rashes. LVN 1 stated TN 1 was responsible for treating and providing updates on the residents with skin conditions to WCPA and Dermatologist.  During a telephone interview on 1/19/2023 at 1 p.m. with the WCPA, the WCPA stated she ordered Ivermectin due to unresolved rashes for Resident 1. The WCPA stated she did not order skin scrapings because it was not offered as one of their (the company in which she works) services.  During an interview on 1/19/2023 at 2:55 p.m. with the IPN, the IPN stated Rehabilitation Staff (RS) 1 informed him, RS 1 went to urgent care on last week of December 2022 (did not specify exact date) and was diagnosed with scabies. The IPN stated the rash to RS 1’s arms did not look like scabies to him. The IPN stated he did not consult with the facility’s Medical Director regarding RS 1’s diagnosis because he believed it did not look like scabies to him. The IPN stated the Dermatologist was visiting the facility every month and the WCPA was visiting on a weekly basis for all the residents with skin problems. The IPN stated the suspicious rashes were not reported to the local Public Health office nor the Department of Public Health. The IPN stated the facility had no confirmed cases of scabies and the IPN was not aware that a suspected case of scabies or rashes needed to be reported.    During a concurrent observation and interview on 1/24/2023 at 10 a.m. with RS 1, in the Rehab room, RS 1 was observed with multiple brown pin-point scars to both arms. RS 1 stated she had multiple red pin-point rashes the last week of December 2022. RS 1 stated she consulted urgent care and was told she had scabies. RS 1 stated she was treated with Permethrin 5% cream. RS 1 stated she reported her diagnosis to the IPN however the IPN did not believe her. RS 1 stated she provided physical therapy treatment for Resident 1 during the month of December 2022 and up until January 2023.  During a concurrent observation and interview on 1/24/2023 at 10:23 a.m. with CNA 3, CNA 3 stated she went to her primary physician in December 2022 (unable to recall exact date) and was told she had scabies. CNA 3 was observed with multiple brown spots on both arms. CNA 3 stated skin scraping was not done and was instructed by her primary physician to apply Permethrin 5% cream at home to her whole body for 24 hours, then shower after. CNA 3 stated she notified the IPN.  During an interview on 1/24/2023 at 10:29 a.m. with LVN 2, LVN 2 stated the Dermatologist visited once a month. LVN 2 stated the last visit was in December 2022. LVN 2 stated the WCPA checked the residents every week. LVN 2 stated Resident 1 had an order and was treated with Ivermectin for widespread dermatitis. LVN 2 stated skin scrapings were important to rule out scabies, properly treat the residents and isolate as needed. LVN 2 stated Resident 1 were noted scratching “a lot lately.”  During a telephone interview with the facility’s Medical Director on 1/24/2023 at 2:50 p.m., the Medical Director stated he was aware there were multiple residents with unresolved rashes, however he was not told there was suspected scabies. Medical Director stated he was aware that there were staff who were diagnosed with scabies, but he was not provided copies of confirmed positive results of scabies. The Medical Director stated the facility’s residents were seen by the Dermatologist for consultations. The Medical Director stated it was dependent on the Dermatologist’s professional expertise if he wanted to order skin scraping for the residents with suspected scabies.  During a concurrent observation and interview on 1/24/2023 at 3:10 p.m. with RS 2, RS 2 stated on 1/3/2023, she went to urgent care for multiple pin-point rashes on both arms. Multiple brown spots were observed to RS 2’s arms. RS 2 stated she was given an order to apply Permethrin 5% cream at home from the neck to the feet and stay for 8-14 hours and then shower. RS 2 stated she was told to laundry all her linen and clothes with hot water. RS 2 stated she reported to the IPN on 1/3/2023 that she went to urgent care, was told she had scabies and had received treatment. RS 2 stated she was not off from work.  During a concurrent observation and interview on 1/24/2023 at 3:20 p.m. with CNA 4, CNA 4 was observed multiple brown spots on his arms and shoulders. CNA 4 stated after 12/25/2022, he went to urgent care for multiple red rashes on his arms and shoulders. CNA 4 stated he had a positive skin scraping and was treated with Permethrin 5% cream. CNA 4 stated he reported his scabies diagnosis to the facility, and he was not placed off work.  During a telephone interview with the Dermatologist on 1/24/2023 at 4:59 p.m., the Dermatologist stated his last visit to the facility was in November 2022. The Dermatologist stated he was not aware there were residents with suspicion of scabies in the facility who were treated with prophylactic medication for scabies and not skin scraped prior to treatment. The Dermatologist stated he was not aware facility staff reported having multiple pin-point rashes, who consulted urgent care and was diagnosed with scabies and treated with Permethrin 5% cream. The Dermatologist stated a skin scraping test could produce a false negative result (a?test?result that indicates that a person does not have a specific disease or condition when the person does have the disease or condition) for many reasons.   During an interview with the IPN on 1/24/2023 at 5:15 p.m., the IPN stated she did not complete a line listing of the residents or staff identified with rashes because no one really complained about being itchy, and the two staff (RS 1 and CNA 3) who reported having rashes were treated. The IPN stated Resident 1 and Resident 2 did not have skin scrapings prior to the administration of the prophylactic medication Ivermectin. The IPN stated Resident 1 was not placed on contact precautions/isolation.  During an interview with the ADM on 1/24/2023 at 5:25 p.m., the ADM stated he was not aware staff (RS 1, RS 2, CNA 3, and CNA 4) reported they had scabies. The ADM stated he did not report the suspected rashes to the Department of Public Health or to the local public health nurse, because there