Health inspection·May 26, 2022

F886 §483.80 (h) COVID-19 Testing. The LTC facility must test residents and facility staff, including individuals providing services under arrangement and volunteers, for COVID-19. At a minimum, for all residents and facility staff, including individuals providing services under arrangement and volunteers, the LTC facility must: §483.80 (h)((1) Conduct testing based on parameters set forth by the Secretary, including but not limited to: (i) Testing frequency; (ii) The identification of any individual specified in this paragraph diagnosed with COVID-19 in the facility; (iii) The identification of any individual specified in this paragraph with symptoms consistent with COVID-19 or with known or suspected exposure to COVID-19; (iv) The criteria for conducting testing of asymptomatic individuals specified in this paragraph, such as the positivity rate of COVID-19 in a county; (v) The response time for test results; and (vi) Other factors specified by the Secretary that help identify and prevent the transmission of COVID-19. §483.80 (h)((2) Conduct testing in a manner that is consistent with current standards of practice for conducting COVID-19 tests; §483.80 (h)((3) For each instance of testing: (i) Document that testing was completed and the results of each staff test; and (ii) Document in the resident records that testing was offered, completed (as appropriate to the resident’s testing status), and the results of each test. §483.80 (h)((4) Upon the identification of an individual specified in this paragraph with symptoms consistent with COVID-19, or who tests positive for COVID-19, take actions to prevent the transmission of COVID-19. §483.80 (h)((5) Have procedures for addressing residents and staff, including individuals providing services under arrangement and volunteers, who refuse testing or are unable to be tested. §483.80 (h)((6) When necessary, such as in emergencies due to testing supply shortages, contact state and local health departments to assist in testing efforts, such as obtaining testing supplies or processing test results. Title 22 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 interventions to prevent and control the spread of Covid-19 (Coronavirus 19 disease, a severe respiratory illness caused by virus and spread from person to person) in accordance with the local Public Health guidelines and the Center of Disease Control and Prevention (CDC) by failing to: a. Ensure to use the required personal protective equipment (PPE, gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator) when providing care to resident infected with Covid-19 in the Red Zone (an isolation area for residents who have laboratory-confirmed COVID -19) or person under investigation (PUI) status, and in the Yellow zone (an isolation area for residents newly admitted, readmitted residents or residents who have symptoms of COVID-19 infection). b. Ensure appropriate visual alert signages for hand hygiene, social distancing, red zone were clearly visible. c. Ensure the door in red zone room (Room A), which was immediately next to a yellow zone room (Room H), was closed. d. Ensure dedicated staff remained in the red zone during an outbreak (is a sudden increase in occurrences of a disease). Licensed Vocational Nurse 2 (LVN 2), who was assigned in the red zone, was observed walking into a yellow zone room at the end of her shift. e. Ensure staff facility’s red zone was clearly identified and physically separated from other zones. f. Ensure to screen all visitors, staff, contract workers, and vendors entering the facility regardless of vaccination status, for signs and symptoms of COVID-19 infection, including a temperature check and verify documentation of COVID 19 immunization or COVID-19 negative test result. g. Implement interventions to prevent and control the spread of COVID-19 to ensure three sampled staff (LVN 1, Certified Nurse Assistant 2 (CNA 2), and CNA 3) were being tested twice a week for COVID-19 and thoroughly documented in the facility's records in accordance with public health guidance. These deficient practices had the potential to further spread the COVID-19 infection to residents, staff, and visitors, and could lead to severe infection, hospitalization, and death. On 3/2/2022, an unannounced visit at the facility to investigate a complaint related to infection control was conducted. a. During an observation on 3/2/2022 at 1:58 pm, CNA 1 was observed in the yellow zone inside Room J providing care to a patient without wearing a gown. In a concurrent interview, CNA 1 stated it was important to wear a gown to protect from any fluid contact or splash from a patient in the yellow zone. During an observation on 3/2/2022 at 2:47 pm, with the Director of Staff Development (DSD), Patient 1 was observed not wearing a protective mask, walking in the red zone hallway. In a concurrent interview, the DSD stated the patient should be inside her room. The DSD then asked the patient to go back to her room, however, the patient continued to walk up to the yellow zone nursing station. The red zone staff, LVN 1 and LVN 2, went up to Patient 1 to redirect patient back to her room. The LVN 1 and LVN 2 were not wearing the proper PPE’s (gloves or gowns) when within six feet of the patient as they walked the Patient 1 back to her room. During an interview on 3/2/2022 at 2:55 pm, DSD stated LVN 1 and LVN 2 should have been wearing gloves or don (put on) PPE when they touch or within six feet of a patient from the yellow or red zone to prevent the spread of infection. A review of the CDC’s guideline, “Covid-19 Infection Control for Nursing Homes,” updated 2/2/2022, indicated Healthcare Personnel (HCP) caring for patients with suspected or confirmed SARS-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator). A review of the CDC’s guideline, “Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes & Long-Term Care Facilities,” updated on 2/2/2022, indicated to Manage Patients with Suspected or Confirmed SARS-CoV-2 Infection. HCP caring for patients with suspected or confirmed SARS-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator). [Source: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html#:~:text=prior%20to%20transfer.-,Manage%20Patients%20with%20Close%20Contact,gowns%2C%20gloves%2C%20eye%20protection%2C%20and%20N95%20or%20higher%2Dlevel%20respirator).,-Patients%20can%20be] A review of the CDC’s guidelines titled, "Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes," updated on 2/2/2022, indicated the following: 1. Patients should only be placed in a COVID-19 care unit if they have confirmed SARS-CoV-2 infection. 2. If a patient requires a higher level of care or the facility cannot fully implement all recommended infection control precautions, the patient should be transferred to another facility that is capable of implementation. Transport personnel and the receiving facility should be notified about the suspected diagnosis prior to transfer. 3. Patients and HCP who are not up-to-date with all recommended COVID-19 vaccine doses should generally be restricted to their rooms, even if testing is negative, and cared for by HCP using an N95 or higher-level respirator, eye protection, gloves, and gown. They should not participate in group activities. [Source: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html#anchor_1631031193599] b. During an observation on 3/2/2022 at 3:08 pm, with the DSD, the second-floor break room was observed not having signage indicating the importance of hand hygiene or social distancing of at least six feet apart. In a concurrent interview, the DSD stated that it was important to remind staff to perform hand hygiene and social distance 6 feet apart to prevent the transmission of Covid-19. During a concurrent observation and interview on 3/2/2022 at 2:40 pm with the DSD, a black and yellow caution tape with a sign “Red Zone” laid on the floor outside Room A. The DSD stated Room A was in the red zone and the caution tape was to indicate between Room A and Room H, which was in the yellow zone, that was located immediately next door. The DSD placed the caution tape back up on the wall between the two rooms. The DSD stated it was important to have a clear signage caution tape up so staff and visitors know this is a red zone room and to prevent the spread of infection. A review of the facility’s policy and procedure, “Covid-19, Prevention and Control,” dated 2/28/2022 indicated that visual alerts would be posted at the entrance and in strategic places to provide patient, staff, and visitors instructions about hand hygiene, PPE donning and doffing, cough etiquette, social distancing visitation alerts and other educational materials on Covid-19. A review of the CDC's guideline, “Covid-19 Infection Control Guidance,” updated 2/2/2022, indicated source control and physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a healthcare setting. This is particularly important for individuals, regardless of their vaccination status, who live or work in counties with substantial to high community transmission. [Source: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#:~:text=Source%20control%20and%20physical,by%20public%20health%20authorities.] A review of the CDC’s guideline, “Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic,” updated 2/2/2022, indicated to post visual alerts [for example (e.g.) signs, posters] at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) with instructions about current Infection Prevention and Control (IPC) recommendations (e.g., when to use source control and perform hand hygiene). [Source: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#:~:text=Establish%20a%20Process,reflect%20current%20recommendations.] c. During an observation on 3/2/2022 at 2:40 pm, with the DSD, the door to Room A located in the Red zone was observed wide open. The patient in Room A was visibly seen from the shared hallway of the red and yellow zone. Room A in the red zone shared a common bay and was immediately next to Room H, which was in the yellow zone. The DSD closed the door to Room A. In a concurrent interview, the DSD stated the doors should be closed to prevent the transmission of COVID-19. A review of the CDC’s, “Covid-19 Infection Control for Nursing Homes Manage Patients with Suspected or Confirmed SARS-CoV-2 Infection,” updated 2/2/2022, indicated it is recommended that the door to the room remain closed to reduce transmission of SARS-CoV-2. This is especially important for patients with suspected or confirmed SARS-CoV-2 infection being cared for outside of the COVID-19 care unit. [Source: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html#:~:text=In%20general%2C%20it,into%20the%20hallway d. During an observation on 3/22/2022 at 4:12 pm, LVN 2 was observed walking into the DSD’s office located in the yellow zone. In a concurrent interview, LVN 2 stated she was designated to work in the Red zone from 7 am to 3 pm. LVN 2 stated she came to the DSD’s office because the DSD asked to speak with her and to get an in-service training. LVN 2 stated there was a designated exit for staff working in the Red zone at the corner stairwell near Room I. LVN 2 stated she was not supposed to cross the Red zone barrier to get to the Yellow zone. LVN 2 stated every member in the Red zone needs to stay in the Red zone, should stay there for the remainder of their shift, and should exit through the designated red zone exit. LVN 2 stated this was important to contain and prevent the spread of Covid-19 infection During an interview on 3/2/2022 at 4:23 pm, IPN stated that staff members assigned to the Red zone must exit through the designated Red zone exit. IPN stated it was extremely important to prevent the spread of COVID-19 positive cases. A review of the facility’s policy and procedure, “COVID-19, Prevention and Control,” dated 2/28/2022 indicated the facility shall implement a staffing plan to limit transmission during an outbreak. The policy indicated dedicated, consistent staffing teams who directly interact with patient that are COVID-19 positive and limiting clinical and other staff who have direct patient contact to a specific unit. The policy indicated there shall be no rotation of staff between floors or wings during the period they are working each day, however, this may change when the facility has staffing shortages. A review of the CDC’s guideline, “Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic,” updated 2/2/2022, indicated facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with SARS-CoV-2 infection. The guideline indicated dedicated means that HCP are assigned to care only for these patients during their shifts. [Source: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#:~:text=Patient%20Placement,the%20same%20room]. A review of the CDC’s guideline, “Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes,” updated 2/2/2022, indicated to identify HCP who will