A COVID-19 Focused Infection Control Survey was conducted by the Oregon State Survey Agency 1/20/21 through 1/29/21.
A deficiency was cited.
Total residents: 28
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
A COVID-19 Focused Infection Control Revisit Survey was conducted by the Oregon State Survey Agency on 3/24/21 to 3/26/21.
The facility was found to be in compliance with 42 CFR 483.80.
Total Residents: 30
Based on observation, interview and record review it was determined the facility failed to follow manufacturer's recommendations for glucometer (a blood sugar monitoring device) disinfection for 1 of 3 halls, to provide infection control signages for 2 of 3 isolation rooms, to provide a personal protective equipment (PPE) cart for 1 of 3 isolation rooms and to ensure staff were disinfecting and storing PPE correctly for 1 of 2 staging areas. This placed residents at risk for infections. Findings include:
1. The manufacturer's guidance for disinfecting the Evencare glucometer recommended several EPA-approved disinfectants which did not include rubbing alcohol.
The facility's policy Use of Blood Glucose Meters/INR Machines dated 10/2017 included instructions to:
- wash hands and wear single-use disposable gloves when taking blood sugars
- prepare a barrier for the machine to be placed on
- after use, disinfect the machine with an approved disinfecting wipe for blood-borne pathogens
- allow the disinfectant to remain on the meter to dry
On 1/20/21 at 4:15 PM Staff 4 (LPN) was observed to perform a blood sugar check on Resident 1 in the resident's room. After it was completed, Staff 4 left the resident's room without changing gloves or sanitizing hands. Staff 4 proceeded to the medication cart holding the glucometer in the same gloved hands along with waste resulting from the procedure. She placed the glucometer on the top of the medication cart without a barrier between the glucometer and the cart surface, continuing with the same gloves she had on when taking Resident 1's blood sugars. When asked about the infection control process, Staff 4 stated she disinfected the glucometer in the resident's room with a rubbing alcohol pad which she felt was enough before placing the glucometer in the cart drawer for use on the next resident. Staff 4 stated she always used rubbing alcohol to disinfect glucometers, that she was not taught differently and there were no EPA-approved wipes for the Evencare glucometer on the cart.
On 1/20/21 at 4:30 PM Staff 1 (Administrator) confirmed the appropriate EPA-approved disinfectant was not on the cart.
On 1/21/21 at 3:28 PM Staff 2 (DNS) agreed the glucometer should not have been disinfected with rubbing alcohol, Staff 4 should have removed her gloves in the resident's room and sanitized her hands and should have place the glucometer on a paper towel barrier on the medication cart to disinfect it with the appropriate disinfectant. Staff 2 agreed Staff 4 needed to be re-educated on glucometer cleaning and hand hygiene.
2. (a) On 1/20/21 at 4:25 PM Staff 4 (LPN) was observed to enter Resident 2's room, which was an isolation room, without full PPE. Staff 4 was asked if she knew Resident 2's room was an isolation room. She stated she did not know it was an isolation room because there were no signs on the door and stated she was also in the room earlier in the afternoon.
On 1/20/21 at 4:30 PM Staff 1 (Administrator) confirmed Resident 2's room was an isolation room and signage should have been on the door.
(b) On 1/20/21 at 5:25 PM Resident 3's room was observed with no precaution signs on the door and no PPE cart outside the door. The resident was readmitted from the hospital and was in isolation as required.
On 1/20/21 at 5:30 PM Staff 1 (Administrator) acknowledged Resident 3 readmitted from the hospital, her/his room should have required signage on the door and a PPE cart outside alerting staff it was an isolation room.
3. On 1/20/21 at 3:30 PM Staff 6 (Personal Care Assistant) was observed getting ready to leave after her shift. She stated she did not keep her eye protection in the facility but took it to her car. She did not understand eye protection needed to be disinfected and left in the facility. She stated no one told her differently.
On 1/21/21 at 1:29 PM Staff 1 (Administrator) agreed Staff 6 needed to leave sanitized eye protection in the facility after her shift and not take it out of the facility. Staff 1 confirmed Staff 6 did not have a container set up at the employee entrance/exit where PPE was sanitized and stored.
1. Appropriate isolation precaution signage and PPE isolation carts were immediately placed for identified rooms. Staff # 4 was educated on proper procedures for appropriate protocols for infection control of glucometers, to include steps to minimize contamination of equipment, cleaning of hands, and appropriate cleaning disinfectant.Staff # 6 was educated on need to sanitize and store eye protection in the facility. A storage container was provided for staff # 6. 2. An audit was conducted of designated isolation rooms to determine appropriate signage and PPE were appropriately placed.Medication carts were audit to determine appropriate disinfectant was available for glucometer sanitation. Audit was conducted to determine employees had appropriate designated storage container for eye protection and disinfectant available.3. The nursing has been educated on proper steps and disinfectant utilized for glucometers; to include avoiding contamination, promote sanitation, and ensure proper protocols and disinfectant used. Competency for every LN has been confirmed and documented.I-Team will determine appropriate communication and steps to ensure isolation signage and PPE carts are placed as required.Staff will be educated on requirement for eye protection to be sanitized and stored in the facility. Facility staff educated on the correct policy and procedure for donning and doffing PPE in every isolation room. Competency is confirmed through the utilization of the AAPACN approved PPE Donning and Doffing Competency Tool.4. DNS/designee will monitor Glucometer steps and sanitization twice a week x 1 month, then weekly x 2 months to ensure proper sanitation. DNS/Designee will monitor isolation rooms for signage, PPE supplies/carts, and appropriate PPE usage daily M-F x 1 month, while isolations rooms are utilizedDNS will report to QAPI monthly x 2 months on glucometer monitoring, signage, PPE supplies/carts, and then as indicated. ADM/designee will ensure eye protection is appropriate sanitized and stored at the facility 2x a week x 2 months and report to QAPI as indicated.
A COVID-19 Infection Control Survey and a COVID-19 Confirmed Facility Review were conducted by the Oregon State Survey Agency 1/20/21 through 1/29/21.
Total residents: 28
A deficiency was cited.
Refer to the Form CMS 2567 dated 1/29/21.
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: Cardiopulonary 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
A COVID-19 Focused Infection Control Revisit Survey was conducted by the Oregon State Survey Agency on 3/24/21 to 3/26/21. The facility was found to be in compliance.
Total Residents: 30
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OAR 411-086-0330 Infection Control and Universal Precautions
Refer to F880
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