Other·April 15, 2022

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 patients 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(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 protocol for five staff members [(Certified Nursing Assistant 1 (CAN 1), Certified Nursing Assistant 3 (CAN 3) Housekeeping 1 (HK 1), Housekeeping 2 (HK 2), Director of Business Development (DBD)] who were required to wear Personal Protective Equipment (equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) when entering the Yellow Zone rooms (isolation room for patients exposed to COVID - 19 [a severe respiratory illness caused by a virus and spread from person to person]), in accordance with the facility's Mitigation Plan (MP, a plan to reduce loss of life and impact of COVID- 19 in the facility) for COVID 19. These deficient practices had the potential to spread Covid-19 infection throughout the facility. During an observation on 2/1/2022 at 10:00 a.m., Yellow Zone signs and PPE donning and doffing (procedure for putting on and removing PPE) signages were posted by the doors, indicating everyone who entered the Yellow Zone rooms were required to wear PPE. During an observation on 2/1/22 at 10:07 a.m., CNA 1 walked out of a Yellow Zone room holding a banana without wearing a face shield, gown, and gloves. CNA 1 reentered the same Yellow Zone room without wearing a face shield, gown and gloves to give juice to a patient. During an observation on 2/1/22 at 10:10 a.m., HK 1 and HK 2 were observed cleaning a Yellow Zone room. HK 1 was not wearing a gown and face shield while mopping the floor. HK 2 was observed in the Yellow Zone room without wearing a face shield, gown, and gloves. During an observation on 2/1/22 at 10:18 a.m., DBD was at the bedside of a patient in the Yellow Zone room and touched the patient’s call light without wearing a face shield and gown. During an interview on 2/1/22 at 10:20 a.m., DBD stated she positioned the patient’s call light in place. DBD stated she was in the Yellow Zone. DBD stated the patient was in the Yellow Zone because of exposure to a COVID 19 positive staff who took care of the patient. DBD stated when she entered the Yellow Room, she should put on a gown and face shield. DBD stated she was supposed to wear a gown and face shield, but she did not stay long in the Yellow Zone room. During an interview on 2/1/22 at 10:35 a.m., HK 1 stated he thought he was cleaning a Green Zone room (area for patients with no known exposure and tested negative for COVID-19) and he did not see the Yellow Zone sign. During a concurrent observation and interview on 2/1/22 at 11:27 a.m., CNA 3 was observed in a Yellow Zone room bringing out a shower chair without wearing a gown and gloves. CNA 3 stated the shower chair was by the window and she only went inside the room to get the shower chair. CNA 3 stated when inside the Yellow Zone room, she should wear gown, mask, and gloves. During an interview on 2/1/22 at 12:20 p.m., HK 2 stated she thought she was cleaning a Green Zone room. HK 2 stated she cleaned the restroom and the tables in the Yellow Zone room. HK 2 stated when inside the Yellow Zone room, she should be wearing gloves, gown, face shield and N95 mask (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of particles transported by air). HK 2 stated the facility placed Yellow Zone and Green Zone signs for the staff to identify the type of room. HK 2 stated PPE was needed to prevent the spread of infection. During an interview on 2/1/22 at 12:25 p.m., CNA 1 stated she took the bananas out from the Yellow Zone room because the patient did not want it and placed them back on the tray. CNA 1 stated she returned to the same Yellow Zone room to bring juice to another patient. CNA 1 stated she forgot to wear gown, gloves, and face shield. During an interview with Infection Prevention Nurse (IPN) on 2/1/22 at 12:37 p.m., she stated, for the Yellow Zone, staff need to enter with full PPE of face shield, N95 mask, gown, and gloves. IPN stated full PPE is required for the Yellow Zone regardless of the time spent in the room. IPN stated it was important to wear PPE to stop the spread of infection. IPN stated the patients in the Yellow Zone were exposed to a COVID 19 positive staff. IPN stated if staff do not wear the required PPE, there was a potential to spread infection to other patients and staff. A review of the facility's undated Mitigation Plan titled, "COVID-19 Mitigation Plan Manual" indicated, in Yellow Cohorts, N95 respirators, goggles or face shield, gowns, and gloves should be worn when providing resident (patient) care (e.g., entering resident room and/or within six feet of resident). The facility failed to implement protocol for CAN 1, CAN 3, HK 1, HK 2, DBD who were required to wear Personal Protective Equipment when entering the Yellow Zone rooms in accordance with the facility's Mitigation Plan for COVID 1. These deficient practices had the potential to spread Covid-19 infection throughout the facility. The above violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of all patients in the facility.