Health inspection·October 29, 2021

§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(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. 72523(c)(3) Patient Care Policies and Procedures (c) Each facility shall establish and implement policies and procedures, including but not limited to: (3) Infection control policies and procedures. The facility failed to implement interventions to prevent and control the spread of COVID19 (Coronavirus disease, a mild to severe respiratory illness that spread from person to person) in accordance with the facility's infection control policy and the Mitigation Plan (MP, plan to reduce loss of life and impact of COVID 19 in the facility) by failing to: a. Hire a full time Infection Control Prevention Nurse (ICPN, a nurse who helps prevent and identify the spread of infectious disease in the healthcare environment) who has completed the required training to monitor, prevent and control the spread of COVID-19 in the facility from 8/7/21 to 9/15/21. b. Complete the Visitor Screening Log from 8/2/21 to 9/15/21 to monitor for signs and symptoms to limit and/or prevent of COVID-19. c. Ensure Licensed Vocational Nurse 1 (LVN1) wear N95 mask while providing treatment to Resident 1 in the Yellow Room (area designated for new admission). These deficiencies had the potential to result in the spread of COVID-19 and put residents and staff at risk for COVID 19 infection that could lead to severe respiratory illness, hospitalization and/or death. On 9/15/21, an unannounced visit was made to the facility to conduct Focused Infection Control Survey. a. During an interview and record review with the Director of Nursing (DON) on 9/15/21, at 9:30 a.m., she stated the Director of Staff Development (DSD) serve as the acting ICPN since the newly hired ICPN2 resigned. 6/12/21 until present. During an interview on 9/15/21 at 10:05 a.m., the Director of Staff Development (DSD) stated she did not take a class for Infection Control and does not have the ICPN training and certificate. The DSD stated her title in the facility has been DSD for three years. During an interview on 9/15/21 at 10:15 a.m., the facility administrator stated ICPN1 was on leave the second week of June 2021. ICPN2 started working as ICPN from 6/16/ 21 to 8/6/21 and then left. The administrator stated the facility had no ICPN for, "2-3 weeks". During an interview on 9/15/21 at 1:20 p.m., the DON stated, the facility did not have an ICPN onsite since 8/7/21. The DON stated the facility's DSD agreed to be trained as ICPN but has not completed the ICPN training. The DON stated she was aware that ICPN training takes about 20-25 hours and she should have an ICPN who has completed the required Infection Control training prior to working as an ICPN. A review of ICPN1's Leave of Absence Request, dated 6/15/21, indicated ICPN1 request for leave was 6/12/21 for up to 8 weeks. The DON approved the leave of absence request on 6/15/21. A review of ICPN2's Letter of Resignation, dated 7/27/21, indicated ICPN2's last day of employment was 8/6/21 as Infection Preventionist at the facility. b. During an interview with Activities Director (AD) and record review of the Visitor Screening Log, on 9/15/21 at 12:00 p.m., a total of 109 pages had incomplete screening from 8/2/21 to 9/15/21. The Visitor Screening Log either had no date or partially dated from 8/2/21 to 9/15/21. During an interview with the facility's receptionist on 9/15/21 at 12:54 p.m., she stated The Visitor Screening Log was incomplete. During an interview on 9/15/21, at 3:15 pm, the DON stated she does not check The Visitor Screening Log for completeness. The DON stated no one was checking The Visitor Screening Log. c. During an interview with the Director of Nursing (DON) on 9/15/21 at 9:15 a.m., she stated the facility has a Yellow Room for new admissions to quarantine for 14 days. The DON stated there were 3 Yellow Rooms. During an observation on 9/15/21, at 2:10 p.m., Licensed Vocational Nurse 1 (LVN 1) wore a surgical mask with face shield inside a Yellow Room. During a concurrent interview, LVN 1 stated she wore a surgical mask and she forgot to wear N95 mask while performing wound treatment to Resident 1 inside the Yellow Room. A review of the facility's COVID-19 Facility Mitigation Management Plan, revised 5/28/31, indicated the facility has a full time, dedicated Infection Preventionist (two staff with split role). The Infection Preventionist has the responsibility for the implementation of the facility's Infection Prevention and Control Program, as well as Infection Prevention Quality Control being an essential member of the QAPI Committee. The Infection Preventionist had received the required training and has the ability to train HCPs on infection prevention and control as well as on the prevention of Healthcare Associated Infections. The Infection Preventionist keeps records and maintains contact with CDPH on the tracking and reporting of COVID-19 cases within the facility. A review of the facility's undated Policy and Procedure titled "COVID-19 Infection Control in Yellow Zone or Yellow Room" indicated to wear N95 mask, face shield and use washable gowns when working directly with residents. The facility failed to implement interventions to prevent and control the spread of COVID19 in accordance with the facility's infection control policy and the Mitigation Plan by failing to: a. Hire a full time Infection Control Prevention Nurse who has completed the required training to monitor, prevent and control the spread of COVID-19 in the facility from 8/7/21 to 9/15/21. b. Complete the Visitor Screening Log from 8/2/21 to 9/15/21 to monitor for signs and symptoms to limit and/or prevent of COVID-19. c. Ensure Licensed Vocational Nurse 1 wear N95 mask while providing treatment to Resident 1 in the Yellow Room. As a result, these violations had the potential to result in the spread of COVID-19 and put residents and staff at risk for COVID 19 infection that could lead to severe respiratory illness, hospitalization and/or death. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of residents.