Other·March 11, 2024

§ 72541. Unusual Occurrences. Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. The facility failed to report a Coronavirus 2019 (COVID-19, an infectious disease) outbreak in the facility, within 24 hours of occurrence of the incident, to the California Department of Public Health in accordance with the facility’s policy and procedure. This failure had the potential to threaten the welfare, safety, or heath of the patients, personnel, or visitors due to the spread of the infectious disease. As a result, the California Department of Public Health was not aware of the incident and could not conduct a timely on-site investigation to ensure the facility was taking proper precautions to ensure the welfare of the patients and staff during this outbreak. On 2/2/2023 at 8:45 AM a.m., an unannounced complaint investigation was conducted regarding a COVID- 19 outbreak at the facility that started on 1/14/2024. A review of Patient 1’s Admission Record dated 2/2/2024, indicated the facility admitted a 70 year old male to the facility on 12/21/23, with diagnoses including Corneal transplant (to remove all or part of a damaged cornea and replace it with healthy cornea tissue from a donor), asthma (is a common long-term condition that can cause coughing, wheezing, chest tightness and breathlessness) and diabetes (is a lifelong condition that causes a person's blood glucose (sugar) level to become too high). A review of Patient 1’s “Minimum Data Set (MDS) -a standardized assessment and screening tool” dated 12/26/23, the MDS indicated Patient 1 was cognitively intact. The MDS indicated Patient 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or contact guar assistance as patient completes activity) during eating, personal hygiene, toileting, sit to lying, chair/bed to chair transfer, partial/moderate assistance (helper does less than half the effort) with shower/bathing self. A review of Patient 1’s Progress Notes dated 1/14/2024 timed at 9:15 AM, indicated Patient 1 had a change in condition. The Progress Note indicated Patient 1 had a fever. The Progress Note indicated the physician was notified. A review of Patient 1’s Progress Notes dated 1/14/2024 timed at 10:22 AM, indicated Patient 1 was “immediately placed on transmission-based precautions (A method or technique of caring for patients who have communicable diseases.) for suspected case of COVID 19... Assessed possible exposures and closed contact exposures... Explained to patient guidelines to COVID 19 and treatment to COVID 19, will be Paxlovid for 5 days [sic]...” A review of Patient 1’s Rapid antigen test for COVID 19 dated 1/14/2024, indicated a positive COVID 19 result. A review of Patient 1’s Order Summary Report dated 1/14/2024, indicated Patient 1 was initiated on Paxlovid (oral antiviral pill used to treat COVID-19 disease) (300/100) oral tablet therapy with Nirmatrelvir- Ritonavir (treat mild to moderate COVID-19 disease) twice a day for 5 days for COVID 19 disease. During an interview on 2/2/2024 at 3:30 PM with the Infection Preventionist Nurse (IP), the IP stated Patient 1 was symptomatic with headache and a fever on 1/14/2024 and tested positive for COVID 19 and was treated with Paxlovid. The IP stated, she did not report the facility’s COVID 19 positive patient (Patient 1) to CDPH because she was told by staff that Patient 1 probably got the virus from his visitors and medical appointments. The IP stated, she should have reported the COVID 19 positive result to CDPH. The IP stated she reported Patient 1’s COVID 19 positive results to Redcap (online survey for skilled nursing facilities [SNFs] to report COVID-19 information [local health officer]). The IP stated she could not provide documented evidence that the COVID 19 outbreak was reported to Redcap. The IP stated she did not follow up and did not have any communication with the local health officer or the LA County Public Health Nurse (PHN). The IP stated, she did not have any proof of confirmation, that she reported it to Redcap [local health officer] or CDPH. During an interview and record review on 2/2/2024 at 4:30 PM with the IP, in the presence of the Administrator (ADM), the IP presented a printed picture of 24 Covid test kits with patients' names written on each kit and 17 Covid test kits with names of staff written on each kit that were tested on Day 1 (1/15/2024) of the facility's COVID 19 exposure. The IP stated, she used the picture of the test kits as her list of patients and staff that were tested on Day 1. The IP stated she should have tested the patients exposed on Day 3 and Day 5 for exposure but did not. The IP stated, she did not have a surveillance tracking log or surveillance tool to track patients and staff who had close exposure with Patient 1. The IP stated it was important to have a surveillance tracking to heightened alertness to people who were exposed to COVID 19 to prevent further spread of the virus. During an interview on 2/2/2024 at 5 PM with the ADM, the ADM stated the facility should have notified CDPH and local health officer or Redcap when Patient 1 was identified as COVID-19 positive on 1/14/2024. The ADM stated the IP should have developed a tracking and surveillance system for COVID-19 when Patient 1 turned out positive for COVID 19 that included those patients/staff that was exposed to prevent the spread of the virus. A review of a LAC DPH document titled “Coronavirus 2019 Guidelines for Preventing and Managing Covid 19 in Skilled Nursing Facilities,” under reporting requirements, (undated), indicated; a) Skilled nursing facility (SNF) are required to report within 24 hours any suspected COVID-19 outbreak to both Public Health (LAC DPH) and Licensing and Certification, b) note: the current COVID -19 outbreak definition for SNFs in Los Angeles County is at least one PCR/NAAT laboratory confirmed case of covid 19 (symptomatic or asymptomatic) OR at least one symptomatic (sign) case with positive SARS-Cov-2 antigen result who has been in the facility for at least 7 days. A review of the facility’s policy and procedure (P&P) titled, “Infection Surveillance (Outcome) and Reporting , revised 12/2023 , indicated; a) facility to maintain an ongoing system designed to identify possible communicable diseases or infections to ensure that measures are taken to prevent any potential outbreaks, b) Outbreaks and/or individual communicable diseases will be reported to local/state health departments or other agencies, according to CDC guidelines. The P&P indicated; 1) infection control surveillance log is maintained by IP, 2) IP/DNS/Designee will review the log during the morning routine to ensure all potential/actual infections outbreaks are being identified, 3) should any patients or staff be suspected or diagnosed as having a reportable communicable/infectious disease according to state- specific criteria, such information shall be promptly reported to appropriate local and/or state health department officials. The facility failed to report a Coronavirus 2019 (COVID-19, an infectious disease) outbreak in the facility, 24 hours of occurrence of the incident, to the California Department of Public Health. This failure had the potential to threaten the welfare, safety, or heath of the patients, personnel, or visitors due to the spread of the infectious disease. As a result, the California Department of Public Health was not aware of the incident and could not conduct a timely on-site investigation to ensure the facility was taking proper precautions to ensure the welfare of the residents and staff during this outbreak. This violation had a direct relationship to the health, safety, and security of Patient 3 and Patient 4, and all patients residing in the facility.