A COVID-19 Focused Emergency Preparedness Survey was conducted by the Oregon State Survey Agency from 12/22/20 to 12/30/20. The facility was found to be in compliance with 42 CFR 483.73 related to E-0024 (b) (6).
Total residents: 26
A COVID-19 Focused Emergency Preparedness Revisit Survey was conducted by the Oregon State Survey Agency on 3/9/21. The facility was found to be in compliance with 42 CFR 483.73 related to E-0024 (b) (6).
Total residents: 24
A COVID-19 Focused Infection Control Survey was conducted by the Oregon State
Survey Agency on 12/22/20 to 12/30/20.
Deficiencies were cited.
Total residents: 26
Abbreviations possibly used in this document:
ADL: activities of daily living
bid: twice a day
BIMS: Brief Interview for Mental Status
CAA: Care Area Assessment
CBG: capillary blood glucose or blood sugar
cm: centimeter
CMA: Certified Medication Aide
CNA: Certified Nursing Assistant
CPR: Cardiopulmonary Resuscitation
DNS: Director of Nursing Services
F: Fahrenheit
FRI: Facility Reported Incident
HS or hs: hour of sleep
LPN: Licensed Practical Nurse
MAR: Medication Administration Record
mcg: microgram
MDS: Minimum Data Set
mg: milligram
ml: milliliters
O2 sats: oxygen saturation in the blood
OT: Occupational Therapist
PCP: Primary Care Physician
PO: by mouth, orally
PRN: as needed
PT: Physical Therapist
RA: Restorative Aide
RAI: Resident Assessment Instrument
RD: Registered Dietitian
ROM: range of motion
RN: Registered Nurse
RNCM: Registered Nurse Care Manager
SA: State Agency
SLP: Speech Language Pathologist
TAR: Treatment Administration Record
tid: three times a day
UA: Urinary Analysis
UTI: Urinary Tract Infection
The findings of the COVID-19 Focused Emergency Preparedness Revisit Survey conducted on 3/9/21 are documented in this report. The facility was found to be in substantial compliance with 42 CFR Part ยง483 Requirements for Long Term Care Facilities.
Based on observation, interview and record review it was determined the facility failed to maintain sufficient certified and licensed nursing staff to meet the acuity needs of the resident population during a COVID-19 outbreak and failed to assure resident safety. This placed residents at risk for delayed assistance and unmet care needs. Findings include:
Observation on 12/22/20 at 2:02 PM, found one Staff 9 (CNA) working between the two halls of the non-COVID unit.
During an interview on 12/22/20 at 2:26 PM, Staff 9 (CNA) reported two CNAs worked the day shift. Staff 9 had the 20 residents on the non-COVID side and another CNA worked on the COVID positive side with 6 residents. Staff 9 reported the charge nurse helped her a few times during the day.
On 12/22/20 at 2:30 PM, record review of the posted Daily Staffing Report, posted near the nursing station, indicated a resident census of 26 with one RN and two CNAs working the day shift and one RN and two CNAs working the evening shift.
On 12/22/20 at 4:50 PM, Staff 11 (CNA) reported she was scheduled to work a double shift and worked the day shift with one other CNA who worked over on the non-COVID side of the facility. Staff 11 stated her primary assignment was the COVID-19 positive unit and this evening there was one CNA working over on the non-COVD side, herself and the charge nurse.
The CNA Sign-up Sheet form provided on 12/22/20 had four CNAs scheduled with two crossed off for the day shift and three scheduled CNAs with two crossed off for the evening shift on 12/22/20.
On 12/23/20 at 10:45 AM, record review of the posted Daily Staffing Report, posted near the nursing station, indicated a resident census of 25 with one RN and two CNAs working the day shift.
On 12/23/20 at 1:08 PM, Resident 4 stated she/he had not had a shower in more than two weeks. Resident 4 stated it did not feel good and she/he wished she/he could have one.
On 12/23/20 at 1:17 PM, Staff 9 reported she was unable to provide resident showers for over two weeks due to being short staffed. Staff 9 stated she had six of the 20 residents which required a two person assist and the charge nurse was able to help her sometimes but there was only one charge nurse for the facility and often busy. Staff 9 acknowledged she did not have time to wash residents' hands prior to passing meal trays.
On 12/23/20 at 1:50 PM, Staff 2 (DNS) stated she did not know what the N and A meant on the bathing forms. Staff 2 returned at 1:53 PM and reported the letters N and A meant not applicable. Staff 2 confirmed this meant not given.
The 12/23/20 record review of the 12/2020 showers for the 19 residents in the ADL book revealed of the combined bathing daily opportunities of 216 days, 24 showers were documented as having been given.
On 12/23/20 at 2:14 PM, Staff 13 (CNA) reported she was unable to give residents showers in over two weeks. Staff 13 reported she had to leave residents in bed if they need a two person assist because there was not enough staff. Staff 13 reported she does not have enough time to provide resident hand hygiene prior to meals due to not having enough time which was due to the facility being short staffed.
On 12/23/20 at 2:21 PM, Staff 1 (Administrator) and Staff 2 acknowledged the staffing shortage and reported they used "all hands-on deck" to help cover.
This Plan of Correction is prepared and submitted as required by law. By submitting this Plan of Correction, The Dalles Health and Rehabilitation does not admit that the deficiencies listed on the CMS Form 2567L exist, nor does the Facility admit to any statements, findings, facts or conclusions that form the basis for the alleged deficiencies. The Facility reserves the right to challenge in legal proceedings, all deficiencies, statements, findings, facts and conclusions that form the basis for the deficiency. F 725 Sufficient Nursing StaffCFR(s): 483.35(a)(1)(2)Resident Specific:No specific resident was identified in this deficiency.Other Residents:The Director of Nursing (DNS) and/or designee has reviewed other residents to ensure the facility maintains sufficient certified and licensed nursing staff to meet the acuity needs of the resident population during a COVID-19 outbreak in order to assure resident safety and to avoid placing the residents at risk for delayed assistance and unmet care needs. Facility Systems:Director of Nursing and Executive Director have been re-educated on ensuring the facility maintains sufficient certified and licensed nursing staff to meet the acuity needs of the resident population during a COVID-19 outbreak in order to assure resident safety and to avoid placing the residents at risk for delayed assistance and unmet care needs. Monitor:The DNS and/or designee will monitor center staffing to ensure the facility maintains sufficient certified and licensed nursing staff to meet the acuity needs of the resident population during a COVID-19 outbreak in order to assure resident needs are met and showers are provided to validate compliance a minimum of 5 times weekly four weeks and monthly for 2 months. Any concerns identified will be addressed immediately, additional education provided and counseling if appropriate. Monitoring results will be presented by the DNS and/or designee at the monthly Performance Improvement meeting. Monitoring results and system components will be reviewed by the Performance Improvement Team for 3 months and periodically thereafter, with subsequent recommendations developed and implemented as deemed necessary. Date of Compliance: February 3, 2021Person Responsible: Director of Nursing and/or designee.
Based on observation, interview and record review it was determined the facility failed to maintain a system for monitoring and immediately isolating residents with signs/symptoms of COVID-19, ensure storage of PPE (personal protective equipment) with environmental cleaning and ability for disinfection procedures, socially distance and wear PPE, for 2 of 2 units. This placed residents at risk for the exposure and contraction of the COVID-19 virus and other infectious diseases. Findings include:
1. Centers for Disease Control and Prevention, Preparing for COVID-19 in Nursing Homes, revised 6/25/20, Evaluate and Manage Residents with Symptoms of COVID-19. Facilities should complete the following: ... "Ask residents to report if they feel feverish or have symptoms consistent with COVID-19... Actively monitor all residents upon admission and at least daily for fever and symptoms consistent with COVID-19. Ideally, include an assessment of oxygen saturation via pulse oximetry. If residents have fever or symptoms consistent with COVID-19, implement Transmission-Based Precautions (TBP). Older adults with COVID-19 may not show common symptoms such as fever or respiratory symptoms. Less common symptoms can include new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell. Additionally, more than two temperatures" above 99 degrees" "might also be a sign of fever in this population. Identification of these symptoms should prompt isolation and further evaluation for COVID-19."
Resident 1 admitted to the facility in 9/2020 with diagnoses including chronic heart failure and chronic kidney disease.
Resident 2 admitted to the facility in 12/2018 with diagnoses including supraventricular tachycardia (heart condition) and diabetes.
Resident 3 admitted to the facility in 5/2019 with diagnoses including chronic obstructive pulmonary disease (lung condition) and heart failure.
Resident 4 admitted to the facility in 8/2018 with diagnoses including asthma, hypertension and atrial fibrillation (heart condition).
Review of Resident 1's health records indicated the facility provided for identifying (i.e., screening), tracking, monitoring and/or reporting of fever, respiratory illness, and/or other signs/symptoms of COVID-19 and included the following:
- Diagnosis of COVID-19 on 12/17/20;
- Form titled The Dalles Health and Rehabilitation Vital Signs for the month of 12/2020 had entries on the 4th, 5th, 6th, and 20th;
- On 12/23/20 the form titled COVID-19 Surveillance Form Surveillance Form and provided on 12/28/20 the additional forms for the 20th and 23rd,
- Nurse's Notes for 12/2020 had three days with vitals recorded;
- No evidence as to when TBP began;
- Observed on the COVID-19 unit on 12/23/20;
- revealed a lack consistency and documentation for monitoring for signs/symptoms of COVID-19.
Review of Resident 2's health records indicated the facility provided for identifying (i.e., screening), tracking, monitoring and/or reporting of fever, respiratory illness, and/or other signs/symptoms of COVID-19 and included the following:
- Diagnosis of COVID-19 on 12/24/20;
- MAR with vitals temperature and oxygen with missing five shifts for 12/1/20 to 12/22/20. Oxygen saturation dropped to 92% three times and 93% two times, from 12/18/20 to 12/22/23;
- On 12/28/20 the form titled COVID-19 Surveillance Form for the month of 12/2020 for the 26th and 27th;
- Nurse notes with vitals recorded for the month of 12/2020 on the 26th of the month;
- revealed a lack consistency and documentation for monitoring for signs/symptoms of COVID-19.
Resident 3's record review of health records the facility provided for identifying (i.e., screening), tracking, monitoring and/or reporting of fever, respiratory illness, and/or other signs/symptoms of COVID-19, revealed the following:
- MAR with vitals temperature and oxygen with missing four shifts for 12/1/20 to 12/22/20;
-Nurse's Notes for 12/2020 had eight entries with no vitals;
-No evidence as to when TBP began;
- revealed a lack consistency and documentation for monitoring for signs/symptoms of COVID-19.
Review of Resident 4's health records indicated the facility provided for identifying (i.e., screening), tracking, monitoring and/or reporting of fever, respiratory illness, and/or other signs/symptoms of COVID-19 and included the following:
- Diagnosis of COVID-19 on 12/24/20;
- MAR with vitals temperature and oxygen with missing eight shifts for 12/1/20 to 12/22/20;
- On 12/28/20 the form titled COVID-19 Surveillance Form for the month of 12/2020 for the 25th, 26th and 27th;
- Nurses Notes entries for 12/2020 were on the 25th, 26th and 27th. Vitals on the 26th were recorded;
- revealed a lack consistency and documentation for monitoring for signs/symptoms of COVID-19.
On 12/23/20 at 11:05 AM, Staff 9 (CNA) reported she took vitals for tempature and oxygen level every shift and she showed the surveyor a CNA form she completed daily. This different form was not found in resident health records and had space for AM and PM entries.
During an interview on 12/23/20 at 1:08 PM, Resident 4 was observed in her/his room on the non-COVID unit with no signs for TBP. Resident 4 was observed with nasal congestion by the sound of her/his voice and sniffle. Resident 4 stated she/he had nasal congestion due her/his allergy medication had "ran out four days ago". At 1:12 PM, Resident 4 was observed with a deep, wet, rattled cough. Resident stated she/he had the cough for a couple days.
On 12/23/20 at 2:12 PM Staff 10 (RN) reported she was the charge nurse for the non-COVID and COVID-19 units. She monitored residents mostly by word of mouth at report on shift change.
On 12/23/20 at 2:22 PM Staff 2 (DNS) stated the facility implemented surveillance plan for identifying, tracking, monitoring, reporting fever (vitals), respiratory illness and other COVID symptoms which was to communicate with staff with signs on the doors, during report at shift change, taking vitals every four hours and every two hours for resident with signs and symptoms. If a resident had signs or symptoms of COVID-19, staff were to report immediately to DNS and Administrator, place the resident on TBP and administer a COVID-19 test. Staff 2 confirmed Resident 4 was not on TBP.
During an interview on 12/24/20 at 2:09 PM, Witness 1 (family member) reported Resident 4 was COVID-19 positive from a test administered several days prior. Witness 1 stated Resident 4 had not had her/his allergy medication for four days and the resident had with nasal congestion and a cough for the past few days.
On 12/24/20 at 3:27 PM, Staff 10 confirmed Resident 2 and Resident 4 were COVID-19 positive from the test given a few days ago. Staff 10 placed Resident 2 and Resident 4 on TBP in their private rooms.
During an interview on 12/30/20 at 10:41 AM, Staff 2 was unable to convey a consistent method of tracking, monitoring and reporting signs and symptoms of COVID-19. Staff 2 acknowledged if a resident had a change in oxygen saturation, nasal congestion or a cough, she would expect more frequent checks implemented and the nurse to start a surveillance sheet. Staff 2 was asked to provide documentation for when Resident 4 was placed on TBP.
Record review and interviews revealed no consistency and lack of documentation in reporting, tracking and monitoring residents for signs/symptoms of COVID-19. Observations were made of Resident 4 with signs/symptoms of COVID-19 and with no TBP on 12/23/20.
On 12/31/20 at 12:00 PM, further information was received.
2. The CDC "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic", revised 11/20/20 instructed facilities to ensure environmental cleaning and disinfection procedures were followed consistently and correctly.
Oregon Health Authority (OHA) consultations were held on 12/10/20 and 12/31/20 to nursing facility. OHA recommendations regarding face shield disinfection and storage directs facilities to organize face shield storage area so face shields are not touching each other or stored with a face mask. Staff should place face shields apart from each other in labeled, clear plastic bags so there is no risk of touching or having staff touch the bag of other staff's face shields. Face masks were to be stored separately in a paper bag. OHA recommendations included removing unused furniture, excessive papers and porous and/or uncleanable objects and surfaces in common areas.
Observations were conducted on 12/22/20 at 2:03 PM and 12/23/20 at 12:57 PM, of the facility staff reusable PPE storage room for face masks and eye protection/face shields. This room was used for disinfection of PPE, COVID-19 staff testing for all staff on the non-COVID and COVID-19 units. Observations revealed the storage room was disorganized and in disarray. Examples included:
- multiple clear plastic bags and paper bags which contained face shields and N95s stored together and touching each other;
- no surface, designated space or station to disinfect face shields;
- instructions on how to don and doff face masks was mostly under a container of hand sanitizer, hand sanitizer dispenser and an open box of face shields;
- multiple papers single, stacked, notebooks and photo type albums;
- multiple boxes of open and unopened PPE;
- COVID-19 testing supplies on table and floor;
- multiple boxes filled with supplies and empty;
- boxes of gloves, Kleenex tissue and DVD movies;
- two oxygen concentrators;
- multiple pieces of furniture including a fabric recliner chair.
In the PPE storage room, on 12/22/20 at 2:13 PM Staff 4 (RN/Infection Preventionist) stated "sorry it's so messy in here".
On 12/22/20 at 2:21 PM, Staff 4 reported face masks were expected to not be stored in the plastic bag with the face shield. Staff 4 stated faces shields were not to be stored in paper bags.
On 12/23/20 at 10:59 PM, Staff 2 (DNS) confirmed the PPE storage room had multiple surfaces which were not able to be disinfected. Staff 2 confirmed the face masks and face shields were not to be stored together in the same bags. Staff 2 acknowledged no space to disinfect face shields and cleared a small space on the back-dresser tabletop.
3. The CDC (Center for Disease Control and Prevention) "Coronavirus Disease 2019 (COVID-19), revised 6/19/20, directed the facility to implement Universal Source Control which referred to face masks to cover a person's mouth and nose to prevent spread of respiratory secretions when talking, sneezing or coughing. Because of the potential for asymptomatic and pre-symptomatic transmission, source control measures are recommended for all staff in the healthcare facility, even if they do not have symptoms of COVID-19. Healthcare providers should wear a facemask at all times while they are in the healthcare facility, including breakrooms or other spaces where they might encounter co-workers. Staff should be aware of the importance of performing hand hygiene immediately before and after any contact with their face masks.
Oregon Health Authority, Public Health Office of Disease Prevention and Epidemiology, dated 7/20/20, instructed "staff should wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected. Face shields or goggles are appropriate, but face shields are preferred as they may provide additional protection for the nose and mouth. Masks and eye protection should be worn at all times while in the facility, including in breakrooms or other spaces where they might encounter co-workers. When masks and eye protection need to be removed (e.g., to eat meals or upon leaving the facility), strict social distancing should be observed."
Review of CDC Considerations for Wearing Masks, updated 11/12/20, showed "A mask is NOT a substitute for social distancing. Masks should still be worn in addition to staying at least 6 feet apart."
On 12/23/20 at 12:27 PM, Staff 6 (Food and Nutrition Services Manager), Staff 7 (Cook) and Staff 8 (Dietary Aide) were observed in the kitchen not be socially distanced, within six feet of each other. Staff 6 and Staff 7 were observed with no face mask or face shield/eye protection while each ate food. Staff 6 promptly put on a face mask and face shield and showed surveyor her empty plate. Staff 8 was observed to touch her face mask and face shield and then touch her clothing with no hand hygiene performed. Staff 6, Staff 7, and Staff 8 acknowledged they were in the kitchen, not socially distanced and Staff 6 and Staff 7 had no face mask or face shield/eye protection.
On 12/30/20 at 10:41 AM, Staff 1 (Administrator) and Staff 2 (DNS) stated they expected face masks and face shields were always worn by staff in facility. An exception was when staff were in the breakroom and socially distanced. Staff 1 and Staff 2 confirmed face masks and face shields were required in the kitchen.
On 12/31/20 at 12:00 PM, no further information was received.
F 880 Infection Prevention & ControlCFR(s): 483.80(a)(1)(2)(4)(e)(f)Resident Specific:No specific resident was identified in this deficiency. Other Residents:The Director of Nursing (DNS) and/or designee has reviewed other residents to ensure the facility maintains a system for monitoring and immediately isolating residents with signs/symptoms of COVID-19, ensuring storage of PPE (personal protective equipment) with environmental cleaning and ability for disinfection procedures, socially distance and wearing of PPE for center units in order to avoid placing residents at risk for the exposure and contraction of the COVID-19 virus and other infectious diseases. Facility Systems:Facility staff have been re-educated on ensuring monitoring and immediately isolating residents with signs/symptoms of COVID-19, ensuring appropriate storage of PPE (personal protective equipment), environmental cleaning and ability for disinfection procedures, and socially distancing and wearing of PPE for center units in order to avoid placing residents at risk for the exposure and contraction of the COVID-19 virus and other infectious diseases. Monitor:The DNS and/or designee will monitor to ensure the facility maintains a system for monitoring and immediately isolating residents with signs/symptoms of COVID-19, ensuring storage of PPE (personal protective equipment), ability for environmental cleaning in PPE storage room, ability for disinfection procedures, and staff socially distance and wear appropriate PPE for center units in order to avoid placing residents at risk for the exposure and contraction of the COVID-19 virus and other infectious diseases through observations to validate compliance a minimum of 5 times weekly four weeks and monthly for 2 months. Any concerns identified will be addressed immediately, additional education provided and counseling if appropriate. Monitoring results will be presented by the DNS and/or designee at the monthly Performance Improvement meeting. Monitoring results and system components will be reviewed by the Performance Improvement Team for 3 months and periodically thereafter, with subsequent recommendations developed and implemented as deemed necessary. Date of Compliance: February 3, 2021Person Responsible: Director of Nursing and/or designee. DPOC Items:Root Cause Analysis conducted including involvement of Infection Preventionist, QAPI Committee and the Governing Body. Findings and intervention plan will be reviewed in January 2021 QAPI meeting.Facility leadership requested and participated in two Infection Control Consult with Oregon Health Authority and other members of Oregon oversight and quality teams as well as local county department of health staff. Education, feedback and recommendations were provided during the consults. Facility leadership has kept notes of the consults/recommendations and they have been reviewed and implemented as of 1/21/2021. Staff in the center will be educated on ensuring monitoring and immediate isolating residents with signs/symptoms of COVID-19, ensuring storage of PPE (personal protective equipment) with environmental cleaning and ability for disinfection procedures, socially distance and wearing of PPE for center units in order to avoid placing residents at risk for the exposure and contraction of the COVID-19 virus and other infectious diseases; to include education related to COVID specific guidance per CDC recommendations. Education will be provided by Infection Preventionist, Director of Nursing and/or Executive Director. Education will be done as follows:Center staff will be educated on appropriate monitoring and immediate isolating residents with signs/symptoms of COVID-19, ensuring storage of PPE (personal protective equipment) with environmental cleaning and ability for disinfection procedures, socially distance and wearing of PPE for center units in order to avoid placing residents at risk for the exposure and contraction of the COVID-19 virus and other infectious diseases using the following:CDC training videos on YouTube titled Sparking Surfaces, Clean hands, closely monitor residents, Keep COVID out, and Lessons. Executive Director, Director of Nursing and Infection Preventionist have been educated through the infection control consult coordinated through Oregon Health Authority. The report of the consult has been provided and reviewed by these members. They also have been educated on CDC recommendations related to PPE use, storage and disinfection. Training content consisted of the information put out for providers on the CDC website and Oregon Health Authority. Compliance will be validated ongoing through routine self-audits with findings reported to the QAPI Committee.DPOC items will be fully completed and implemented by February 3, 2021.
A COVID-19 Infection Control Survey and a COVID-19 Confirmed Facility Review were
conducted by the Oregon State Survey Agency on 12/22/20 to 12/30/20.
Total residents: 26
Deficiencies were cited.
Abbreviations possibly used in this document:
ADL: activities of daily living
bid: twice a day
BIMS: Brief Interview for Mental Status
CAA: Care Area Assessment
CBG: capillary blood glucose or blood sugar
cm: centimeter
CMA: Certified Medication Aide
CNA: Certified Nursing Assistant
CPR: Cardiopulmonary Resuscitation
DNS: Director of Nursing Services
F: Fahrenheit
FRI: Facility Reported Incident
HS or hs: hour of sleep
LPN: Licensed Practical Nurse
MAR: Medication Administration Record
mcg: microgram
MDS: Minimum Data Set
mg: milligram
ml: milliliters
O2 sats: oxygen saturation in the blood
OT: Occupational Therapist
PCP: Primary Care Physician
PO: by mouth, orally
PRN: as needed
PT: Physical Therapist
RA: Restorative Aide
RAI: Resident Assessment Instrument
RD: Registered Dietitian
ROM: range of motion
RN: Registered Nurse
RNCM: Registered Nurse Care Manager
SA: State Agency
SLP: Speech Language Pathologist
TAR: Treatment Administration Record
tid: three times a day
UA: Urinary Analysis
UTI: Urinary Tract Infection
The findings of the COVID-19 Focused Emergency Preparedness Revisit Survey conducted on 3/9/21 are documented in this report. The facility was found to be in substantial compliance with OAR 411 - 85 through 89.
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OAR 411-086-0330 Infection Control and Universal Precautions
Refer to F880
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OAR 411-086-0100 Nursing Services: Staffing
Refer to F 725
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