Health inspection·February 12, 2021

T22 DIV5 CH3 ART5-72523(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. F880=E §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. The facility failed to implement interventions to prevent and control the spread of COVID-19 (a mild to severe respiratory illness caused by Coronavirus that can spread from person to person) for two sampled residents (Residents 1 and 2) by failing to ensure: 1. Dedicated staff assigned to COVID-19 positive residents (Red Zone) and not at the same be assigned to Green Zone (COVID-19 negative). 2. The staff break rooms were not shared between staff caring for residents in the Yellow (area for residents suspected and/or exposed to COVID-19 positive person) and Red Zone. 3. A designated restroom was available to staff in Red Zone. 4. A proper doffing area with trash bins located inside the resident rooms in Red and Yellow Zone. 5. The residents' vital signs and symptoms of COVID-19 were done every four hours and performed by the licensed nurses in Red Zone. 6. Dedicated full-time Infection Preventionist (IP). These deficient practices had the potential to increase the numbers of positive COVID-19 cases in the facility and further result in the spread of COVID-19 to the community. An unannounced visit to the facility was conducted on 12/11/20 at 2:15 pm with the Public Health Nurse (PHN) to investigate infection control practice. A review of the current outbreak status from the facility's daily self-reported COVID-19 calls dated 12/9/2020 indicated the facility had an increasing number of confirmed COVID-19 staff and resident within 14 days. The facility had a total of one confirmed COVID-19 positive resident in the Red Zone area and 15 suspected COVID-19 residents in the Yellow Zone area. The facility had 14 confirmed COVID-19 positive staff. 1a. A review of Resident 1's Face Sheet (Admission record), indicated Resident 1, a 100 year-old, re-admitted to the facility on 3/18/19, with a diagnoses including aphasia (loss of ability to understand or express speech, caused by brain damage), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and essential hypertension (a rise of blood pressure of unknown cause). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 12/10/20, indicated the resident required extensive assistance with bed mobility, eating, dressing, personal hygiene and totally dependent on staff with transfer and toilet use. During a concurrent interview and record review of the 24-hour assignment sheet on 12/11/20 at 2:40 pm, Licensed Vocational Nurse 1 (LVN 1) stated she was assigned to 28 residents in the Green Zone and one resident in the Red Zone. During a telephone interview on 12/11/2020 at 7:29 pm, LVN 2 stated she gives medication to Resident 1 in Red Zone at 9 pm then she goes back to nursing station in the Green Zone. During a telephone interview on 12/16/2020 at 11:35 am, LVN 3 stated that she gave medication to two residents in the Red Zone at 10 am, then went back to the nursing station in the Green Zone. A review of Resident 1's Medication Administration Record (MAR) in 12/2020 indicated, Vitamin C tablet was given at 5 pm and Remeron (a medication used to treat depression) was given at 9 pm on 12/9/20, 12/10/20, and 12/11/20, this MAR was validated by LVN 1 and LVN 3. 1b. A review of Resident 2's Face Sheet (Admission record), indicated Resident 2, an 82 year-old, re-admitted to the facility on 9/11/19 with a diagnoses including muscle weakness, diabetes (disease that affects how the body uses glucose, a sugar that is the body's main source of fuel) and essential hypertension (a rise of blood pressure of unknown cause). A review of Resident 2's MDS, dated 12/18/20, indicated the resident required supervision with eating and extensive assistance with bed mobility, transfer, dressing and personal hygiene. During a concurrent interview and record review on 1/5/2021 at 9:35 am, LVN 3 stated she administered Resident 2's (located in the Red Zone) medication at 8 am and 11 am. LVN 3 stated she went back to the nursing station after the medication administration. Electronic Medical Administration Record (eMAR) dated 12/2020, indicated Resident 2 received medications at 8 am and artificial tears eye drops at 11 am on 12/9/20 to 12/15/20. A review of the Centers for Disease Control and Prevention's (CDC) Infection Control Guidance, dated 12/14/2020, indicated as a measure to limit HCP (health care personnel) exposure and conserve PPE (personal protective equipment such as gown, goggles, gloves, and masks used to prevent the spread of infection), facilities could consider designating entire units within the facility with dedicated HCP, to care for patients with suspected or confirmed COVID-19 infection. Dedicated means that HCP are assigned to care only for these patients during their shifts. A review of the facility's Mitigation Plan (MP) dated 6/27/20, indicated for the Red Zone, dedicated, consistent staff who directly interact with COVID-19 positive residents will be limited and there will be no rotation of staff between floors during shift. A review of Los Angeles County Public Health (LAC PH) Coronavirus-19 guidance titled, "B73-Skilled Nursing Facilities," dated 12/30/20, indicated staff assigned to the Red Cohort (sharing space with residents who are treated as a group) should not care for patients in other cohorts if possible. If staff must care for residents in multi cohorts, they should visit the Red Cohort last. 2. During an observation on 12/11/2020 at 2:52 pm, there was no designated breakroom for staff assigned to work in the Yellow Zone. The breakroom was for the staff in both Green and Yellow Zone to use, with maximum occupancy of two persons at a time. 3. During an observation of the Red Zone on 12/11/2020 at 3 pm, the designated Red Zone staff restroom was observed located outside of the Red Zone. Staff assigned to the Red Zone must exit and unzip the plastic barrier to access the restroom located through the double doors. There was no signage posted identifying the restroom was only dedicated for staff in the Red Zone. During an interview on 12/11/2020 at 3:05 pm, Certified Nursing Assistant 1 (CNA 1) stated restroom for the Red Zone staff was available outside of the Red Zone. CNA 1 stated to access the restroom, the staff had to unzip the plastic barrier to pass the double doors. A review of an undated facility's policy and procedures titled, "Infection Control," indicated to prevent spread of infection; the facility will try to limit the movement of HCP from one location to another location as much as possible. 4. During a concurrent observation and interview on 12/11/2020 at 2:24 pm, covered trash bins were located outside the rooms in Yellow Zone with signage indicating "trash only". The Director of Nursing (DON) stated the staff doff their PPEs after patient care in the hallway and dispose their PPEs in the designated bins. The DON stated there were no spaces available inside the rooms for trash bin. During an observation on 12/11/2020 at 3:05 pm, and in the presence of the DON, one covered trash bin was observed outside Resident 1's room for PPE disposal after care. Another trash bin was also observed located outside of the plastic barrier of the Red Zone for PPE disposal. The DON stated the covered trash bin located outside of the Red Zone was used for staff to dispose their PPEs when coming from the Red Zone. The DON proceeded to remove the trash bin. A review of facility's policy and procedures titled, "Personal Protective Equipment," with a revision date of September 2010, indicated when removing mask and gloves, discard mask and gloves into the designated waste receptacle inside the room. A review of the Centers for Disease Control and Prevention, Infection Control for Nursing Homes, dated 11/20/20, indicated to position a trash can near the exit inside the resident room to make it easy for staff to discard PPE prior to exiting the room or before providing care for another resident in the same room. 5. During an interview on 12/11/2020 at 2:40 pm, LVN 1 stated that resident's vital signs (measurements taken to help assess the general physical health of a person, give clues to possible diseases, and show progress toward recovery) and COVID-19 symptoms were assessed every shift (8 hours) in the in Yellow and Red Zone. During an interview on 12/16/2020 at 3:45 pm, CNA 2 stated residents’ vital signs were obtained in the Red Zone every four hours. CNA 2 stated when assessing for signs and symptoms of COVID-19, no licensed nurse was present during these assessments. A review of the facility's MP, dated 6/27/2020, indicated a licensed nurse screens all SNF (skilled nursing facility) residents for signs and symptoms of COVID-19. The MP further indicated residents with suspected symptoms, assessments are conducted twice a shift by a licensed nurse. A review of CDPH All Facilities Letter (AFL, a letter to all healthcare facilities with updates) 20-25.2 document titled, "Assessment of California Skilled Nursing Facilities to Receive Patients with Confirmed COVID-19 Infection indicated, Strategies,” indicated to review facility processes for monitoring vital signs (including pulse oximetry) every 4 hours for resident with COVID-19 infection. 6. During an interview on 12/11/2020 at 3:02 pm, the DON stated there was no dedicated full-time IP. The DON stated the IP's responsibilities were shared by the DON, Assistant Director of Nursing (ADON), and the Director of Staff Development (DSD). The DON further stated that the IP's responsibilities were assigned as of 2016, and the facility has been actively seeking a full-time IP. The DON stated she was responsible for both the resident and staff line listing (investigation of outbreaks for unexplained respiratory illnesses). During an interview on 12/11/2020 at 3:30 pm, the ADON stated the IP role was shared amongst the ADON, the DSD and the DON. The ADON stated there was not one full-time dedicated IP. During an interview on 12/15/2020 at 12:23 pm, the ADON stated her main responsibility was to assist the DON on help needed within the facility. The ADON stated she was now the designated temporary full-time IP for the facility as of 12/14/2020. A review of the DON and ADON's timecard dated 11/29/20 to 12/26/20, indicated her work hours for the week to equal 40 hours. There was no record indicating the DON and the ADON divided their time to fulfill the duties of having a full time IP in the facility. A review of the DSD's timecard dated 11/29/20 to 12/26/20 indicated an overtime of 16.75 hours for one month. The card indicated the DSD did not fulfill the duties of having a full time IP in the facility. A review of CDPH's AFL 20-85 dated 11/9/2020, indicated SNF's should have a full time, dedicated IP that may be shared by two staff members, if the total time dedicated to the IP role is equivalent to one full-time staff member. The facility failed to ensure each facility shall establish and implement policies and procedures, including but not limited infection control policies and procedure, including but not limited to: The facility failed to implement interventions to prevent and control the spread of COVID-19 for two sampled residents (Residents 1 and 2) by failing to ensure: 1. Dedicated staff assigned to COVID-19 positive residents (Red Zone) and not at the same be assigned to Green Zone (COVID-19 negative). 2. The staff break rooms were not shared between staff caring for residents in the Yellow and Red Zone. 3. A designated restroom was available to staff in Red Zone. 4. A proper doffing area with trash bins located inside the resident rooms in Red and Yellow Zone. 5. The residents' vital signs and symptoms of COVID-19 were done every four hours and performed by the licensed nurses in Red Zone. 6. Dedicated full-time Infection Preventionist (IP). These deficient practices had the potential to increase the numbers of positive COVID-19 cases in the facility and further result in the spread of COVID-19 to the community. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.