Health inspection·August 2, 2024

§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. 22 CCR § 72311. Nursing Service--General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. 22 CCR §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. On 6/26/2024 the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility reported incident (FRI) regarding infection control. The facility failed to implement interventions to prevent and control scabies (a highly contagious skin condition caused by the itch mite that infests and irritates your skin), per the facility policy and procedure (P&P) tiled, "Scabies Identification, Treatment and Environmental Cleaning," for four of four sampled residents (Residents 1, 2, 3 and 4), by failing to: 1. Identify and detect symptoms of scabies and provide treatment for Resident 1 when the resident had a skin rash on 6/7 and 6/8/2024. 2. Control the spread of scabies by placing Resident 1 on contact precautions (isolation precautions, actions taken to prevent the or control infections) when Resident 1 was being treated with Elimite and Ivermectin on 6/11/2024 and diagnosed with scabies on 6/13/2024. 3.Maintain contact precautions, per the Physician's Order on 6/13/3024 4. Implement control measures to prevent the transmission of scabies among residents in the facility, staff, and visitors. As a result, the facility did not adhere to its Scabies P&P and had a potential of transmitting scabies to 86 inhouse residents, the staff, and community. a. A review of Resident 1's admission record indicated the facility re-admitted the resident on 6/7/2024 with diagnoses including chronic respiratory failure (a condition in which your lungs have a hard time loading your blood with oxygen or removing carbon dioxide), pneumonia and heart failure (condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). The admission record also indicated the facility was Resident 1's responsible party. A review of Resident 1's General Body care plan initiated 3/22/2024, indicated the resident was diagnosed with dermatitis unspecified and had a positive skin scraping for scabies on 6/13/2024 (one week after admission). The care plan interventions indicated for staff to check resident's skin to determine affected areas, dermatologist consult, follow up treatment as needed, and the facility staff was to perform a skin scraping and to place Resident 1 on contact precautions (initiated on 6/13/2024). A review of Resident 1's Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated 4/10/2024, indicated Resident 1's cognition was severely impaired (never/rarely made decisions) and was totally dependent upon staff for all activities of daily living (ADLs - essential and routine activities include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet). The MDS also indicated Resident 1 had one Stage IV pressure injury (full thickness tissue loss with exposed bone, tendon, or muscle). A review of Resident 1's Body Check form for readmission to the facility, dated 6/7/2024, indicated Resident 1 had a generalized body rash, but did not indicate the areas on the body where the rash was located. The Body Check form, dated 6/8/2024, indicated the resident was reassessed and a general rash. The body check form did not include a measurement for the rash. A review of Resident 1's History and Physical (H&P), dated 6/8/2024 indicated the resident did not have the capacity to understand and make decisions. The H&P did not address Resident 1's body rash in accordance with the Body Check form on 6/7/2024. According to a review of Resident 1's Body Check form, dated 6/11/2024, the resident's rash was diagnosed as dermatitis (a common condition that causes swelling and irritation of the skin. It has many causes and forms and often involves itchy, dry skin or a rash). A review Resident 1's Dermatology Progress Notes, dated 6/11/2024, indicated Resident 1 was diagnosed with generalized body dermatitis and the treatment included Elimite (generic name permethrin), topical steroids (anti-inflammatory preparation used to treat skin conditions), Ivermectin (medication used to treat diseases caused by parasites) and oral steroids. A review of Resident 1's Situation Background Assessment and Recommendation (SBAR - a documentation of a complete assessment in response to a change in condition [COC]), dated 6/11/2024 at 1 PM, indicated Resident 1 was seen by the dermatologist and was observed with a generalized rash. The resident received a shower and creams were applied to relieve the skin from further damage. The SBAR form indicated the Certified Nursing Assistants (CNAs) and family members were educated to be gentle with skin and not rub or scrub the skin. A review of the Physician's Order, dated 6/11/2024, indicated Resident 1 was to receive: -One tube of Elimite 5% cream applied from neck to toes, leave on for 12 hours then rinse and to repeat once a week for four weeks. - Three Ivermectin (an anti-parasitic medication used to treat worms, head lice and skin conditions) 3 milligram (mg) oral tablets for a total of 9 mg once a week for four weeks. - Clobetasol 0.05% cream applied to general body rash twice a day for four weeks. - Prednisone (a steroid medication) 20 mg tablet twice a day for five days. A review of Resident 1's Medication Administration Record (MAR) for June 2024 indicated the resident received three Ivermectin three mg tablets for a total of a nine mg dose via g-tube once a week every Wednesday for three doses on 6/12 and 6/19/2024. According to a review of Resident 1's Treatment Administration Record (TAR) for June 2024, the resident received two of four total doses ordered of Elimite treatment on 6/13 and 6/20/2024. A review of the Physician's Order, dated 6/12/2024, indicated Resident 1 was to have a skin scraping to rule out scabies. A review of Resident 1's SBAR a form, dated 6/12/2024 at 12 AM, indicated, "There were no situational facts given for the SBAR." A further review of the SBAR indicated the primary physician ordered the medications Ivermectin and Elimite and ordered Resident 1 to receive a skin scraping. A review of the Physician's Order, dated 6/13/2024, indicated the facility was to place Resident 1 on contact precautions due to the resident being positive for scabies. A review of Resident 1's Laboratory Result, dated 6/13/2024, indicated the resident was examined for scabies and the results indicated Resident 1 was positive for scabies adults and eggs. A review of the At Risk for further Skin Breakdown Care Plan, initiated 6/26/2024, indicated the goal was for Resident 1's skin condition to resolve with no further damage. The care plan interventions included for Resident 1 to avoid scratching and keep hands and body parts from excessive moisture and to keep fingernails short. The treatment order included to cleanse with normal saline, pat dry, paint with betadine, apply xeroform and cover with a dry dressing. b. A review of Resident 2's admission record (roommate of Resident 1) indicated the facility re-admitted the resident on 6/9/2022, with diagnoses including presence of a tracheostomy (a surgical opening created through the neck into the windpipe to allow air to fill the lungs), hepatomegaly (enlargement of the liver beyond its normal size) and diabetes (high blood sugar). A review of Resident 2's H&P dated 6/5/2024, indicated the resident had the capacity to understand and make decisions. The H&P also indicated the resident had the current skin conditions of eczema (skin dryness) and moisture associated skin damage (MASD, inflammation of the skin caused by sources of moisture such as urine, perspiration, stool or mucus). A review of the Physician's Orders, dated 6/11/2024, indicated Resident 2 was to receive application of Permethrin External cream (Elimite) 5% from neck to toes, leave on for 12 hours, then rinse and to repeat once a week for four weeks. A review Resident 2's Dermatology Progress Notes, dated 6/11/2024 indicated Resident 2 was diagnosed with generalized body dermatitis and the treatment included Elimite, topical steroids (anti-inflammatory preparation used to treat skin conditions), Ivermectin and oral steroids. According to a review of Resident 2's Treatment Administration Record (TAR) for June 2024, the resident received two of four total doses ordered of Elimite treatment on 6/13/2024 and 6/20/2024. c. A review of Resident 3's admission record (roommate of Resident 1) indicated the facility re-admitted the resident on 12/14/2022 with diagnoses including cellulitis (skin infection), quadriplegia, epilepsy, and dementia. A review of Resident 3's MDS, dated 6/4/2024, indicated the resident's cognition was severely impaired (never/rarely made decisions) and the resident was completely dependent upon staff for all ADLs. The MDS further indicated Resident 3 did not have an open lesion or laceration. A review of the Resident 3's Body Check form, dated 6/8/2024, indicated the resident had skin issues and a generalized rash, but there was no measurement for the rash or location of the rash specified. A review of Resident 3's Dermatology Progress Notes, dated 6/11/204, indicated Resident 3 had folliculitis on her abdomen and back. A review of the Physician's Orders, dated 6/13/2024, indicated the following: - Resident 3 was to have skin scraped to rule out scabies and - Resident 3 was to be placed on contact precautions due to exposure to scabies positive roommate. - The facility was to apply Elimite 5% topical cream apply from neck to toes then to rinse after 12 hours for one administration due to exposure. According to a review of Resident 3's Treatment Administration Record (TAR) for June 2024, the resident was treated with Elimite treatment on 6/14/2024. d. A review of Resident 4's admission record (roommate of Resident 1) indicated the facility re-admitted the resident on 10/11/2023 with diagnoses including chronic respiratory failure, atrial fibrillation, and ventilator dependent. A review of Resident 4's MDS, dated 4/3/2024, indicated Resident 4's cognition was severely impaired, was totally dependent upon staff for all ADLs and the resident had a Stage IV pressure injury. The MDS further indicated Resident 4 did not have an open lesion or laceration. A review of Resident 4's Dermatology Progress Report, dated 6/11/2024, indicated Resident 4 was diagnosed with eczema on her arms. A review of the Physician's Orders, dated 6/13/2024, indicated the following: - Resident 4 was to have her skin scraped to rule out scabies - Resident 4 was to be placed on contact precautions due to exposure to scabies positive roommate. - The facility was to apply Permethrin 5% topical cream apply from neck to toes then to rinse after 12 hours for one administration due to exposure. A review of Resident 4's Treatment Administration Record (TAR) for June 2024 indicated the resident was treated with Elimite treatment on 6/13/2024. During an interview on 6/26/2024 at 8:40 AM, the Infection Preventionist (IP) stated Resident 1 was recently readmitted to the facility. Resident 1 was evaluated by the dermatologist (DERM), who also evaluated Residents 2, 3, and 4, who were all roommates. The IP stated Resident 1's test for scabies was positive. The IP further stated Resident 1 was never isolated from the other roommates and Resident 1 never had a room change. The IP stated, "We began to test the whole unit for scabies on 6/12/2024." During an initial tour of the facility on 6/26/2024 at 8:51 AM, Residents 1, 2, 3 and 4's room was observed. Resident 1, 2, 3, 4 were present in their respective beds. During observation, there was signage outside of the room which indicated Resident 1, 2, 3 and 4 were on enhanced barrier precautions which required everyone to clean their hands, including before entering and when leaving the room. The signage did not indicate staff or visitors were required to wear gown and gloves at all times when in the room. During an interview on 6/26/2024 at 8:56 AM, Licensed Vocational Nurse (LVN) 1 stated Resident 1 returned to the facility after hospitalization with a rash. Resident 1 returned to the same room with the same roommates and had never changed rooms. LVN 1 stated Resident 1 was tested for scabies a week after returning to the facility and was positive. During an observation on 6/26/2024 at 9:07 AM with Treatment Nurse (TN) 1, Resident 1's skin assessment was observed. During a concurrent interview, TN 1 stated Resident 1 had new body scratches. TN 1 stated Resident 1's medial thigh had multiple scratches that removed the top layer of skin, and the surrounding area was very red. TN 1 also stated Resident 1 had open scratches to her mid back, right and left buttocks and left hip. On 6/27/2024 at 10:10 AM, during a concurrent interview and record review with LVN 1, Resident 1's electronic chart was reviewed. For the SBAR form dated 6/11/2024, LVN 1 stated that on 6/11/2024 there was a change in Resident 1's skin condition and the doctor diagnosed Resident 1 with unspecified dermatitis due to a general body rash. After review of Resident 1's physician's orders, LVN 1 stated the physician ordered a skin scraping for Resident 1 on 6/12/2024