Other·June 5, 2023

42 CFR §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. 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. 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. (B) Development of an individual, written patient care plan, which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. The California Department of Public Helath (CDPH) received a Facility Reported Incident (FRI) on 4/19/23 regarding the facility had 21 residents with skin rashes. On 5/2/2023, CDPH conducted an unannounced investigation at the facility. The facility failed to: 1. Establish and maintain an infection prevention and control program for scabies (a contagious, intensely itchy skin condition caused by a tiny, burrowing mite) for eight residents (Resident 1, Resident 2, Resident 3, Resident 7, Resident 8, Resident 19, Resident 21 and Resident 26) after facility was informed Resident 1 (who was transferred from the facility to a general acute care hospital [GACH] on 3/25/2023 with rashes) was diagnosed and treated for scabies on 3/26/2023 and returned to the facility on 4/4/2023. 2. Inform Resident 1’s dermatologist ([Medical Doctor (MD) 2] a medical practitioner specializing in the diagnosis and treatment of skin disorders), to report Resident 1 was diagnosed and treated with scabies on 3/26/2023 at the GACH, to further investigate and treat other six Residents (Resident 1, Resident 3, Resident 7, Resident 8, Resident 19, and Resident 21) who were itchy, have rashes and were exhibiting symptoms of scabies. 3. Address the rashes noted for six residents (Resident 1, Resident 3, Resident 7, Resident 8, Resident 19, and Resident 21) who were exhibiting symptoms of scabies. 4. Treat Resident 2 (Resident 1’s roommate) prophylactically (a medicine or course of action used to prevent disease), after being exposed to Resident 1, who was treated and diagnosed with scabies. 5. Ensure Certified Nurse Assistant (CNA) 1, (who did not receive prophylactic treatment after exposure to residents who were suspected of having scabies), wore personal protective equipment ([PPE] protective clothing or equipment worn to protect against infectious materials) when providing care to residents, Resident 1 and Resident 26, who were in a contact isolation (precautions taken when a patient has an infectious disease that may be spread by touching either the patient or other objects the patient has handled). CNA 1 placed Resident 1 and 26 at high risk for exposure to scabies. 6. Adhere to the facility’s policy and procedure titled, “Scabies Prevention and Control,” which stipulates to identify possible cases of scabies infection as soon as possible, skin scrapings (a definitive scabies test that identifies mites, eggs, or eggshell fragments embedded in the skin) will be performed as ordered for suspected cases, place all residents and staff suspected of scabies in contact precaution, wear PPE when providing care to residents to prevent the potential spread of scabies. These deficient practices placed 109 Residents, all staff, vendors, and visitors at risk for scabies exposure. 1. A review of Resident 1’s Admission Record (Face Sheet), dated 4/25/2023, the Face Sheet indicated Resident 1 was a 72 years old female, was initially admitted to the facility on 10/28/2022, and readmitted on 4/4/2023. Resident 1’s diagnoses included Raynaud’s syndrome (a condition in which some areas of the body feel numb and cool in certain circumstances), alcoholic liver disease (liver damage caused by excess alcohol intake), chronic obstructive pulmonary disease ([COPD] a group of lung diseases that block airflow and make it difficult to breath) and anemia (a condition in which blood does not have enough healthy red blood cells). A review of Resident 1’s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 2/3/2023, the MDS indicated the cognitive (the ability to think and process information) skills for daily decisions making was intact. Resident 1 required extensive assistance in dressing, limited assistance in personal hygiene, and limited assistance in bed mobility. A review of Resident 1’s document, titled “Change of Condition ([COC] a clinical deviation from a resident's baseline) Assessment Form”, dated 2/20/2023, at 9:30 p.m., indicated Resident 1 expressed concerns over a new onset rash with redness, scabbing, and extreme itchiness on the trunk of her body, and upper extremities. COC indicated Resident 1 denied being exposed to any known allergens (iodine, and sea food). COC indicated Licensed Vocational Nurse (LVN) 1 notified Resident 1’s primary physician (MD) 1. MD 1 ordered Triamcinolone Acetonide Cream (used to treat the itching, redness, dryness, crusting, scaling, inflammation, and discomfort of various skin conditions) for generalized (all over the body) rash. A review of Resident 1’s Physician Order, dated 2/21/2023, indicated an order for Triamcinolone Acetonide Cream 0.1 % topically (on the surface of the body) every morning and evening shift for 30 days for generalized body rash. A review of Resident 1’s Physician Order, dated 2/28/2023, indicated an order for Hydrocortisone External Gel (used to treat skin conditions by suppressing the immune response, relieving itch) every morning and evening shift for generalized body rash for 30 days. A review of Resident 1’s Physician Order, dated 2/28/2023, indicated, a dermatology consult was ordered eight days after onset of rash. During an interview on 4/20/2023, at 12:45 p.m., with Registered Nurse (RN) 2, RN 2 stated, Resident 1 originally had the rash on 2/20/2023, was readmitted to the facility on 4/4/2023 from the GACH, and was treated for scabies (3/26/2023) during her hospitalization, prior to readmission on 4/4/2023. During a concurrent observation and interview on 4/21/2023, at 11:35 a.m., inside Resident 1’s room, Resident 1 was observed with a pimple-like red rash and residual scarring on arms, legs, and chest. Resident 1 stated her rash started approximately on 2/20/2023, eight weeks before she was hospitalized on 3/25/2023. Resident 1 stated that the physician in the hospital told her she had scabies. Resident 1 stated she still felt itchy today (4/21/2023). A review of Resident 1’s Physician Order, dated 4/4/2024, indicated an order for Benadryl (used to treat sneezing, runny nose, watery eyes, hives, skin rash, itching, and other cold or allergy symptoms) 25 mg ([milligram] unit of measurement) every 6 hours as needed for itchiness. During a concurrent interview and record review on 4/21/2023 at 2:15 p.m., with Clinical Manager (CM) 1, Resident 1’s Physician Orders, Dermatology Notes, and Nurses Notes from 2/20/2023 to 4/21/2023 were reviewed. CM 1 stated a dermatology consult was ordered for Resident 1 on 2/28/2023. CM 1 stated Resident 1’s clinical record indicated she was only seen by MD 2 on 4/17/2023. CM 1 stated there was no dermatology notes from 2/20/2023 up until 4/17/2023 to address Resident 1’s new onset rash on 2/20/2023. CM 1 was unable to explain why a dermatology consult was not done for Resident 1 as ordered. A review of Resident 1’s documents from MD 2, Resident 1’s dermatology records indicated MD 2 did a consult for Resident 1 on 4/17/2023. Resident 1’s Dermatology Order, dated 4/17/2023, indicated the folowing orders: * Permethrin 5% cream, apply one tube from neck to toes, leave for 12 hours then rinse. Repeat once a week times four weeks. * Ivermectin (an anti-parasite medication used to treat parasitic diseases, and scabies) 12 mg once a week times four weeks. A review of Resident 1’s Medication Administration Record (MAR), dated 4/2023, the MAR indicated, Permethrin 5% cream was administered on 4/19/2023 to Resident 1, by RN 2. A review of Resident 1’s MAR, dated 4/2023, the MAR indicated, Ivermectin 12 mg was administered on 4/20/2023 to Resident 1, by LVN 2. A review of Resident 1’s Physician Order, dated 4/21/2023, indicated an order for a skin scraping for Resident 1. During an interview on 4/20/2023, at 10:50 a.m., with Treatment Nurse (TN) 1, TN 1 stated Resident 1 had a history of the generalized body rash since 2/20/2023. A review of Resident 1’s GACH record, titled “Physian History and Physical”, dated 3/26/2023, indicated Resident 1 was admitted on 3/25/2023 at 10:54 p.m. Resident 1’s history of present illness / chief complaint included a scabies appearing rashes. The Infectious Disease note indicated a diagnosis of Ectoparasitic infestation (condition in which organisms live primarily on the surface of the host) scabies and Permethrin, Ivermectin and contact isolation were ordered. A review of Resident 1’s GACH record, titled, “Physician’s Progress Note Infectious Diseases”, dated 3/30/2023, indicated Resident 1 was itching, had scattered diffused papules (a raised, pimple-like growth on the skin that does not produce pus) and burrows (a tunnel made in or under the skin) on upper extremities, chest, abdomen, lower extremities and skin excoriation (linear erosion of skin tissue resulting from mechanical means) of bilateral buttocks. The GACH record indicated Resident 1’s diagnosis included Ectoparasitic Infestation, scabies . Resident 1 was treated with Permethrin, Ivermectin on 3/26/2023, and was placed on contact isolation. During a concurrent interview and record review on 4/21/2023, at 2:29 p.m., with CM 1, CM 1 reviewed Resident 1’s GACH discharge summary record dated 4/5/2023 indicating Resident 1 was treated for scabies at the GACH on 3/26/2023. CM 1 stated she does not know if the hospital informed facility staff, upon readmission, that Resident 1 was treated for scabies during her hospitalization. During an interview on 4/25/2023, at 3:35 p.m., with the Director of Nursing DON, the DON stated she screened all residents prior to admission, and reviews the GACH records for the residents’ diagnosis and what kind of treatment residents received from the GACH. The DON stated Resident 1’s GACH records indicated Resident 1 was treated for scabies on 3/26/2023. The facility should had initiated an investigation of other residents with skin rashes and scabies exposure upon knowledge of Resident 1’s scabies treatment during hospitalization to prevent the potential spread of scabies. 2. A review of Resident 2’s Face Sheet, dated 4/25/2023, the Face Sheet indicated Resident 2 was a 64 years old female, was admitted to the facility on 3/16/2023. Resident 2’s diagnoses included diabetes mellitus (body has high sugar levels for prolonged periods of time), hypertension (blood pressure that is higher than normal), and muscle weakness (lack of muscle strength that affects mobility). A review of Resident 2’s MDS, dated 3/23/2023, the MDS indicated Resident 2’s cognitive skills for daily decision making was intact, and Resident 2 required extensive assistance in dressing, toileting, personal hygiene and bed mobility. During an interview on 4/21/2023, at 10:50 a.m., with Resident 2, Resident 2 stated she and Resident 1 were roommates prior to Resident 1’s transfer to the GACH on 3/25/2023. They (Resident 1 and Resident 2) were also roommates when Resident 1 returned to the facility on 4/4/2023 until 4/15/2023. Resident 2 stated Resident 1 had told her the doctor in the hospital said she (Resident 1) had scabies. Resident 2 stated she suspected that scabies had been why all the showers have been taking place for other residents the past couple of days, but the facility staff have not communicated anything to her regarding the potential exposure to scabies. Resident 2 stated she did not receive or was offered any creams or treatments for scabies. During a concurrent interview and record review, on 4/21/2023, at 2:15 p.m., with CM 1, the Facility Census dated 3/25/2023 to 4/21/2023 was reviewed. CM 1 stated that Resident 1 and Resident 2 were roommates on 3/25/23, prior to Resident 1’s transfer to GACH, where Resident 1 was treated for scabies. CM 1 also stated Resident 1 and Resident 2 were roommates from 4/4/2023 to 4/15/2023. A review of Resident 2’s Dermatology Order, dated 4/17/2023, indicated an order for Permethrin 5% cream, apply one tube from neck to toes, leave for two hours then rinse for prophylactic treatment. A review of Resident 2’s Dermatology Progress note, dated 4/17/2023, MD 2 progress note indicated Resident 2 was seen by MD 2, who determined no skin pathology was seen on general body, and treatment plan was to administer Elimite prophylaxis (precautionary measure taken to prevent the onset of scabies). A review of document, titled, “Scabies Outbreak Line List for Healthcare Facilities: Patients”, dated 4/18/2023, indicated that Resident 2 who was exposed to Resident 1, was not on the line list. During an interview, on 4/21/2023, at 2:30 p.m., with the DON, the DON stated she was not sure why Resident 2 was not added to the line list and treated prophylactically for scabies. A review of Resident 2’s “Change of Condition Assessment Form” (COC), dated 4/21/2023, the COC indicated on 4/21/2023 at 4 p.m., RN 2 discussed recommendation from dermatologist with the primary physician (MD1) to treat Resident 2 for dermatitis [sic]prophylactically and obtained an order for prophylactic treatment on 4/21/2023. COC indicated Resident 2 was notified of a new order for prophylactic treatment but refused treatment. COC did not indicate the physician was notified Resident 2 was refusing treatment to determine what other orders could be done to mitigate potential spread of scabies. A review of Resident 2’s Physician Order, dated 4/21/2023, indicated, Permethrin External Cream was ordered on 4/21/2023 at 2:31 p.m., by MD 2. A review on of Resident 2’s MAR, dated 4/2023, indicated, Permethrin External Cream (5%) was administered on 4/24/2023 to Resident 2, by LVN 3. During an interview on 4/25/2023, at 12:57 p.m., with the DON, the DON stated the facility should have identified Resident 2 did not receive prophylactic treatment on 4/17/2023, and Resident 2 could have spread scabies to other staff or residents since she was exposed to Resident 1 on 4/15/2023. The DON was unable to explain why Resident 2 did not receive prophylaxis treatment for scabies when MD 2 ordered Elimite ([Permethrin] an insecticide, used to treat scabies on 4/17/2023. 3. A review of Resident 3, Resident 7, Resident 8, Resident 19, and Resident 21's clinical records, the records indicated the residents did not receive treatment for scabies when Resident 1 returned to the facility on 4/4/23, with a disgnosis of scabies. The records indicated the following: a. A review of Resident 3’s Face Sheet, dated 4/18/2023, the Face Sheet indicated Resident 3 was a 92 years old female, was initially admitted to the facility on 5/23/2022, and readmitted on 4/1/2023. Resident 3’s diagnoses included functional quadriplegia (complete immobility and inability to move due to severe physical disability), ventilator dependence (inability to breath independent of a machine device), and hypertension. A review of Resident 3’s MDS, dated 2/24/2023, the MDS indicated Resident 3’s cognitive skills for daily decision makin