Other·February 18, 2022

§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 infection control practices for COVID-19 (Coronavirus disease, a mild to severe respiratory illness that spread from person to person) in accordance with Division of Occupational Safety and Health (Cal/OSHA ) and facility’s Mitigation Plan( a plan to reduce loss of life and impact of COVID 19 in the facility) for COVID-19 for three staff members (Licensed Vocational Nurses 2, 3 [LVN 2, 3] and Registered Nurse 1 [RN 1]) by failing to: 1. Ensure LVNs 2, 3 and RN 1 did not re-use N95 respirator (a protective device designed to achieve a very close facial fit and efficient filtration of airborne [transported by air] particles) over multiple shifts or extended use with multiple patients in the same shift when used for respiratory protection for quarantined patients (Yellow Zone). 2. Ensure LVN 3 and RN 1 disinfected the face shield/eye goggles after patient interaction. These violations had the potential to result in the spread of COVID-19 and put patients and staff at risk for COVID 19 infection that could lead to severe respiratory illness, hospitalization and/or death. On 11/23/21, an unannounced visit was made to the facility to conduct a complaint investigation on infection control, quality of care and nursing services During a concurrent observation and interview on 11/23/21, at 1:56 p.m., with Licensed Vocational Nurse (LVN) 2, in the hallway, LVN 2 was wearing an eye goggle and a N95 respirator. LVN 2 stated she works in the Green Zone (area for patients with no known exposure and tested negative for COVID-19) and Yellow Zone (area for quarantined or COVID-19 symptomatic patients). She stated she was wearing the same N95 respirator for 3 days. LVN 2 stated she wore the same N95 respirator for a maximum 3 days and change it when soiled. She stated she does not change the N95 respirator in between patient care in the Yellow and Green Zones. During an observation on 11/23/21 at 1:52 p.m., in the storage room, multiple boxes of new N95 respirators were observed. During an interview on 11/23/21 at 2:10 p.m., the Director of Nursing (DON) stated the facility does not have shortage of Personal Protective Equipment (PPE, such as gowns, gloves, face shields, goggles, facemasks/respirators). During an interview on 11/23/21 at 3:28 p.m., the facility's Infection Preventionist (IP, nurse who helps prevent and identify the spread of infection in a healthcare environment) stated, the facility does not have a designated staff for Yellow and Green Zone. The IP stated staff were wearing the same N95 respirators throughout the shift and should be changed when soiled. The IP stated there was a total of four newly admitted patients in the Yellow Zone currently, with three patients not vaccinated against COVID-19, and one partially vaccinated patient. During an interview on 11/23/21 at 4:22 p.m., with Registered Nurse 1 (RN 1), RN 1 stated he was working in the Yellow and the Green Zone. RN 1 stated N95 respirator was changed every 3 days or when visibly soiled. RN 1 stated the same N95 respirator was used during the whole shift while working in the Green and Yellow Zone. RN 1 stated the face shield was disinfected approximately about three times during the shift. During an observation on 11/23/21 at 4:27 p.m., LVN 3 was observed not changing the N95 respirator and not disinfecting the face shield when exiting out of the Yellow Zone patient's room. LVN 3 stated N95 respirators needed to be changed when soiled. A review of the facility's undated "COVID-19 Mitigation Plan Manual," indicated, the decision to implement policies that permit extended use or limited reuse of N95 respirators should be made by the professionals who manage the institution's respiratory protection program, in consultation with their occupational health and infection control departments with input from the state/local public health departments." A review of Cal-OSHA guideline, dated 8/6/2020, indicated when patients are cohorted together, the maximum recommended respirator extended use period is 8 to 12 hours. https://www.dir.ca.gov/dosh/coronavirus/Interim-Guidance-on-Severe-Respirator-Supply-Shortages.pdf The facility failed to implement infection control practices for COVID-19 (Coronavirus disease, a mild to severe respiratory illness that spread from person to person) in accordance with Division of Occupational Safety and Health (Cal/OSHA ) and facility’s Mitigation Plan for COVID -19 for three staff members (Licensed Vocational Nurses 2, 3 [LVN 2, 3] and Registered Nurse 1 [RN 1]) by failing to: 1. Ensure LVNs 2, 3 and RN 1 did not re-use N95 respirators (a respiratory protective device designed to achieve a very close facial fit and efficient filtration of airborne particles) over multiple shifts or extended use with multiple patients in the same shift when used for respiratory protection for quarantined patients (Yellow Zone). 2. Ensure LVN 3 and RN 1 disinfected the face shield/eye goggles after patient interaction. As a result, these violations had the potential to result in the spread of COVID-19 and put patients 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 patients.