Health inspection·June 2, 2023

F880 Infection Prevention & Control §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 § 72525. Required Committees. (c) Committee composition and function shall be as follows: (2) Infection control committee. (A) An infection control committee shall be responsible for infection control in the facility. (D) The functions of the infection control committee shall include, but not be limited to: 1. Establishing, reviewing, monitoring and approving policies and procedures for investigating, controlling and preventing infections in the facility. 2. Maintaining, reviewing and reporting statistics of the number, types, sources and locations of infections within the facility. § 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. An unannounced visit was conducted by California Department of Public Health on 4/19/23 at 7:14 AM to investigate a facility reported incident regarding possible GI (GI, relating to, affecting, or including both stomach and intestine) outbreak. The facility failed to ensure an effective infection prevention and control program to prevent infectious disease outbreak (a sudden rise in the number of cases of a disease) for Patients 1, 2, 3 and 8 by failing to: 1. Control the spread of unknown gastrointestinal (outbreak when Patients 1, 2, and 3 were not placed on contact isolation precautions (intended to prevent transmission of infectious agents, which are spread by direct or indirect contact with the patient or patient's environment) on the onset of GI symptoms. Patient 1 was not placed on contact isolation until 4 days after onset of diarrhea (loose watery stool). Patients 2 and 3 were not placed on isolation until two (2) days after onset of diarrhea and vomiting. 2. Ensure Certified Nurse Assistant 1 (CNA 1) wear gloves and isolation gown on 4/19/2023 while pushing Patient 8’s wheelchair inside the patient's room, who was on contact isolation precaution. 3. Ensure CNA 1 wear gloves and isolation gown in the patient's room while feeding Patient 8 who was on contact isolation precaution on 4/19/2023. These deficient practices placed 82 patients, facility staff and visitors at risk for contracting GI infection , and resulted to nine (9) patients (Patients 1,2, 3, 4, 5, 6, 7, 8, and 9) experiencing GI symptoms (vomiting and/ or diarrhea). 1. During a concurrent review of the facility's undated Gastroenteritis (an inflammation of the lining of the stomach and intestines) Illness Outbreak Line List (provides a template for data collection and active monitoring of both patients and staff during a suspected gastroenteritis outbreak) and interview with the DON on 4/19/2023 at 8:04 am, the DON verified the following: a. Patient 1 experienced diarrhea and vomiting on 4/13/2023. b. Patient 2 and 3 experienced vomiting on 4/15/2023 c. Patient 4 experienced diarrhea and Patients 5, 6 and 7 experienced vomiting on 4/16/2023 d. Patient 8 experienced diarrhea on 4/17/2023 e. Patient 9 experienced watery diarrhea on 4/18/2023 The DON stated the GI outbreak was reported to CDPH on 4/17/2023 and local public health on 4/18/2023. The DON stated the GI outbreak should have been reported to CDPH and local public health on 4/15/2023. A review of Patient 1's Admission Record indicated Patient 1 is a 94- year- old- male who was admitted to the facility on 7/12/2021, with diagnoses that included unspecified atrial fibrillation (a serious abnormal heart rhythm characterized by rapid and irregular beating), heart failure (a chronic condition in which the heart cannot pump blood as well as it should) and essential hypertension (abnormal high blood pressure that is not the result of a medical condition). A review of Patient 1's Minimum Data Set (MDS, a comprehensive assessment and care screening tool), dated 1/11/2023, indicated Patient 1's cognitive (mental processes, ability to understand and make decision) skills for daily decision making was severely impaired. Patient 1 required limited assistance for transfers, dressing and eating. Patient 1 required extensive assistance for toilet use and personal hygiene. A review of Patient 1's Interdisciplinary (IDT, involving two or more disciplines or fields of study) notes, dated 4/13/2023, timed at 10:52 am, indicated Patient 1 had greenish yellow emesis (vomiting) on his shirt. Interdisciplinary notes further indicated according to Patient 1, he had vomited once in the morning. A review of Patient 1's IDT notes, dated 4/17/2023, timed at 2:35 pm, indicated Patient 1 was placed on contact isolation precaution (4 days from GI symptoms onset) due to episode of vomiting on 4/13/2023. During an interview on 4/19/2023 at 8:01 am, the DON stated, Patient 1 had diarrhea and vomiting on 4/13/2023. The DON stated, an unnamed facility staff called the physician (MD) who ordered laboratory work which included a comprehensive metabolic panel (CMP, blood tests that give an overall picture of your body's metabolism and chemical balance) and complete blood count (CBC, a test that counts the cells that make up your blood). The DON stated the MD did not order a stool culture (checks for presence of abnormal bacteria in the digestive tract/gastrointestinal tract that may cause diarrhea and other problems). The DON stated, Patient 1 was placed on isolation precaution on 4/17/2023, 4 days after patient presented with vomiting and diarrhea. The DON stated isolation precaution was not and should have been initiated for Patient 1 prior to 4/17/2023 but facility staff did not report Patient 1's GI symptoms to the DON not until 4/17/2023. The DON stated, Patient 1 should have been placed on contact isolation immediately on the onset of GI symptoms on 4/13/2023 to prevent spread of infection amongst other patients residing in the facility. A review of Patient 2's Admission Record indicated the patient is a 97- year- old- female who was initially admitted to the facility on 8/4/2021, with diagnoses that included essential hypertension, unspecified dementia (condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems) and hyperlipidemia (have too many lipids [fats] in the blood). A review of Patient 2's MDS, dated 2/1/2023, indicated Patient 2's cognitive skills for daily decision making were severely impaired. Patient 2 required limited assistance (patient highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance))for transfers, dressing and eating. Patient 2 required extensive assistance for toilet use and personal hygiene. A review of Patient 2's IDT notes, dated 4/15/2023, timed at 3:13 am, indicated Patient 2 was found seated at the edge of bed and stated, "I threw up in the bathroom." A review of Patient 2's IDT notes, dated 4/15/2023, timed at 2:09 pm, indicated monitoring for episodes of nausea and vomiting. The Interdisciplinary notes further indicated Patient 2 had two episodes of vomiting during the shift. A review of Patient 3's Admission Record indicated the patient is a 96- year- old- female who was admitted to the facility on 7/14/2021, with diagnoses that included unspecified dementia, essential hypertension, and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should). A review of Patient 3's MDS, dated 2/1/2023, indicated Patient 3's cognitive skills for daily decision making was severely impaired. Patient 3 required limited assistance for transfers, dressing, eating, toilet use and personal hygiene. A review of Patient 3's Interdisciplinary notes, dated 4/15/2023, timed at 10:06 pm, indicated Patient 3 was being monitored for an episode of vomiting after lunch. A review of Patient 3's Interdisciplinary notes dated, 4/15/2023, timed at 10:19 pm, indicated that after Patient 3 took two scoops of mashed potato during dinner, Patient 3 vomited medium amount of brown colored emesis. During an interview on 4/19/2023 at 1:07 pm, the DON stated on 4/15/2023 Patients 2 and 3 presented with vomiting. The DON stated, MD did not order a stool culture for Patients 2 and 3. The DON stated, Patients 2 and 3 were placed on contact isolation precautions on 4/17/2023, 2 days after both patients presented with vomiting. The DON stated, Patients 2 and 3 should have been placed on contact isolation immediately on the onset of GI symptoms on 4/15/2023. 3. A review of Patient 8’s Admission Record indicated the patient is a 104- year- old- female who was initially admitted to the facility on 5/5/2021, with diagnoses of unspecified dementia, difficulty walking and hypertension. A review of Patient 8’s MDS, dated 1/24/2023, indicated Patient 8 was severely impaired with cognitive skills for daily decision making. Patient 8 required limited assistance for eating and extensive assistance (patient involved in activity, staff provide weight-bearing support) for transfers, dressing toilet use and personal hygiene. During an observation outside of Patient 8’s room on 4/19/2023 at 9:00 am, signage was posted on the wall near the patient's door indicating Patient 8 was on contact precaution. There was an isolation cart directly outside for personal protective equipment (PPE, used to prevent or minimize exposure to hazards). CNA1 entered Patient 8’s room only wearing a mask. CNA1 was not wearing a gown or gloves. During an interview on 4/18/2023 at 9:01 am, CNA1 stated, Patient 8 was on contact precautions but was allowed to leave the room and go to the beauty salon, which was in the facility's basement. CNA1 stated she does not wear PPE when entering Patient 8’s room but usually wears a gown or gloves when assisting Patient 8 to the restroom and cleaning Patient 8 after use of the restroom. During a concurrent observation and interview on 4/18/2023 at 9:04 am, CNA1 stated Patient 8’s beauty salon schedule was canceled and had to wheel Patient 8 back to her room. CNA1 did not put on gloves or isolation gown once inside room. CNA1 stated she did not but was supposed to wear gloves because she was touching the handle of Patient 8’s wheelchair. During an interview on 4/18/2023 at 9:14 am, License Vocational Nurse 1 (LVN 1) stated, she was not sure if staff have to wear gloves and gowns when pushing a wheelchair for a patient that was on contact precautions. During a concurrent observation in Patient 8’s room and interview on 4/19/2023 at 12:47 pm, CNA1 was observed assisting Patient 8 with setting up the meal tray for the patient. CNA1 was observed not wearing an isolation gown or gloves while in the patient's room. CNA1 stated she was rushing because Patient 8 needed assistance with feeding and should have put on PPE. During interview on 4/19/2023 at 12:55 pm, the DON stated, if a patient was on contact isolation precaution, staff must wear an isolation gown and gloves. The DON also stated PPE needs to be donned (put on) right before entering a room on contact isolation, to protect self. The DON stated the staff must put on PPE when setting up a food tray and when pushing patient's wheelchair to prevent spread of infection amongst other patients residing in the facility. A review of the facility's policy and procedure (P&P) titled, "Outbreak of Communicable Diseases," revised September 2022, indicated all Employees and Staff: a. Follow standard precautions at all times, and transmission-based precautions as indicated; and b. Report all symptoms relating to the current disease outbreak to the supervisor A review of the facility's P&P titled, "Unusual Occurrence Reporting," revised December 2007, indicated the facility will report the following events to appropriate agencies: a. An outbreak of any communicable disease. The P&P indicated unusual occurrences shall be reported via telephone to appropriate agencies required by current law and or regulations withing twenty-four (24) hours of such incident or as otherwise required by federal and state regulations. A review of the CDC guidelines titled, "Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings," dated 2007, indicated Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens (organism that causes disease), especially those that have been implicated in transmission through environmental contamination https://www.cdc.gov/infectioncontrol/guidelines/isolation/precautions.html The facility failed to ensure an effective infection prevention and control program to prevent infectious disease outbreak (a sudden rise in the number of cases of a disease) for four (4) of 4 sampled patients (Patients 1, 2, 3 and 8) by failing to: 1. Control the spread of unknown gastrointestinal (GI, relating to, affecting, or including both stomach and intestine) outbreak when Patients 1, 2, and 3 were not placed on contact isolation precautions (intended to prevent transmission of infectious agents, which are spread by direct or indirect contact with the patient or patient's environment) on the onset of GI symptoms. Patient 1 was not placed on contact isolation until 4 days after onset of diarrhea (loose watery stool). Patients 2 and 3 were not placed on isolation until two (2) days after onset of diarrhea and vomiting. 2. Ensure Certified Nurse Assistant 1 (CNA 1) wear gloves and isolation gown on 4/19/2023 while pushing Patient 8’s wheelchair inside the patient's room, who was on contact isolation precaution. 3. Ensure CNA 1 wear gloves and isolation gown in the patient's room while feeding Patient 8 who was on contact isolation precaution on 4/19/2023. These deficient practices placed 82 patients, facility staff and visitors at risk for contracting GI infection and resulted to nine (9) patients (Patients 1,2, 3, 4, 5, 6, 7, 8, and 9) experiencing GI symptoms (vomiting and/ or diarrhea). The above violation had a direct or immediate relationship to the health, safety, or security of Patient 1, 2, 3 and 8.