A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) Seattle on 11/9/20 and 11/10/20. The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Total residents: 60
A COVID-19 Focused Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) Seattle on 11/9/20 and 11/10/20.
The survey sample, based on a resident census of 60, included 3 sampled residents and 12 unsampled residents.
CMS Seattle federal surveyors can be reached at:
US Department of Health and Human Services
Centers for Medicare and Medicaid Services
701 Fifth Avenue Suite 1600
Region 10, mailstop 400
Seattle, WA 98104
206.615.2313
206.615.2088 (Fax)
A COVID-19 Focused Infection Control Revisit Survey was conducted by the Oregon State Survey Agency on 4/6/21 - 4/7/21.
The facility was found to be in substantial compliance with 42 CFR Part §483 Requirements for Long Term Care Facilities.
Total residents: 58
Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases, including COVID-19 and infections. COVID-19 is an infectious disease by a new virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death.
Specifically:
1. Failed to allow sufficient dwell time for disinfecting, per manufacturer's instructions, when cleaning/disinfecting shared glucometer for 4 of 4 observations for unsampled residents (R) (R4, R5, R6).
2. Failed to allow sufficient dwell time for disinfecting, per manufacturer's instructions, when cleaning/disinfecting high-touch items in 1 of 1 resident room observation of daily room cleaning (Room #22) and 2 of 2 hallway hand rails observed (1st and 2nd floor).
3. Failed to change gloves during 1 of 1 unsampled resident (R7) personal care observation when going from dirty tasks to clean tasks.
4. Failed to remind/encourage 2nd floor residents to wear cloth face coverings when out of their rooms.
5. Failed to ensure personal protective equipment face shields were fully covering and protecting sides of eyes from potential splashes and sprays during 3 observations; (Certified Nursing Assistant (CNA) 2 and CNA3).
These failures increased the risk for the spread of infection and its associated discomfort and decline in physical condition.
Findings include:
During an interview on 11/9/20 at 8:20 AM Administrator stated that the facility census was 60. The facility currently did not have any COVID-19 positive residents with their most recent COVID-19 positive resident completing their 20 day isolation and transferred out of the COVID unit. The COVID unit was now closed. Facility had sufficient inventory of PPE (personal protective equipment) and all staff were required to wear PPE comprised of surgical face mask and face shield with addition of gown and gloves for residents in transmission based precautions.
Review of Centers of Disease Control and Prevention (CDC) cases and deaths by county, https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/county-map.html, dated 10/28/20, accessed 11/6/20, showed Linn County (the county where the facility was located) had 3.4 percent positivity rate indicating low level of community COVID-19 activity/green zone positivity classification.
Findings include:
1. Glucometer
During a concurrent observation and interview on 11/9/20 at 11:11 AM showed Licensed Nurse (LN)1 enter R4's room with Assure Plantinum glucometer (Glucometer is a blood glucose meters device that measure blood glucose levels), lancet, alcohol swab, strip, and packet of PDI Super Sani-Cloth. LN1 washed hands and placed a paper towel on resident's overbed table and place glucometer and other supplies on paper towel. LN1 donned gloves and placed strip into glucometer, swab resident's finger with alcohol and then pricked finger with lancet with a small bead of blood shown. LN1 brought glucometer towards blood and blood was shown on the strip inserted in glucometer. Blood sugar reading was obtained. LN1 opened Super Sani-Cloth packet and removed wipe and wiped glucometer. LN1 handed glucometer to surveyor, upon request, and glucometer was dry to touch when touched at 56 seconds after start of disinfecting wipes use. Surveyor asked LN1 to touch glucometer and LN1 confirmed glucometer was dry. LN1 stated the glucometers were shared and used on multiple residents who received medication from the same medication cart. LN1 stated that glucometers were cleaned between residents to make sure it wasn't contaminated. After gathering additional supplies for blood sugar check for R5, LN1 entered R5's room and repeated same steps to obtain blood sugar measurement with same glucometer used for R4. LN1 again wiped glucometer with Super Sani-Cloth after obtaining blood sugar results and after 1 minute and 19 seconds, glucometer was touched and was found to be dry to touch. When asked, LN1 confirmed glucometer was dry to touch and stated that she was not sure when the glucometer became dry.
During concurrent record review and interview on 11/9/20 at 11:29 AM LN1 reviewed the label of the Super Sani-Cloth packet which showed directions "to disinfect nonfood contact surfaces only. Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for a full two (2) minutes."
Observation on 11/10/20 at 7:39 AM showed LN2 enter R4's room with Assure Plantinum glucometer, lancet, alcohol swab, strip, and packet of PDI Super Sani-Cloth. LN2 used hand sanitizer and then placed a paper towel on resident's overbed table and place glucometer and other supplies on paper towel. LN2 donned gloves and placed strip into glucometer, swab resident's finger with alcohol and then pricked finger with lancet with a small bead of blood shown. LN2 brought glucometer towards blood and blood was shown on the strip inserted in glucometer. Blood sugar reading was obtained. LN2 had glucometer in gloved hand, peeled off glove by wrapping glucometer inside glove. LN2 opened Super Sani-Cloth packet and removed wipe and wiped glucometer. LN2 handed glucometer to surveyor, upon request, and glucometer was dry to touch when touched at 1 minute 15 seconds after start of disinfecting wipes use. LN2 confirmed and stated "dry now" and then read the label of the Super Sani-Cloth packet. LN1 further stated that she didn't think the glucometer stays wet even with towel on it, "if that's the concern." LN2 stated the glucometers were shared and used on multiple residents. After gathering additional supplies for blood sugar check for R6, LN2 entered R6's room and repeated same steps to obtain blood sugar measurement with same glucometer used for R4. LN1 again wiped glucometer with Super Sani-Cloth after obtaining blood sugar results and after 55 seconds, glucometer was touched and was found to be dry to touch. When asked, LN1 confirmed glucometer was dry to touch and stated "this product wipe is too small to keep wet for 2 minutes unless we encapsulate it."
During an interview on 11/10/20 at 9:19 AM Infection Preventionist (IP) stated that glucometers are used on multiple residents and cleaned and disinfected between use which included a dwell time of two minutes, which means the surface should remain wet for two minutes. When observations and interviews with LN1 and LN2 was shared, IP confirmed glucometers were not disinfected "they are not doing it".
Review of facility policy, "Diabetic Testing-CNA II Procedure", dated 8/1/2003, showed "Follow manufacturer's directions for the equipment used in your facility .....Clean and disinfect glucometer machine after each resident use by using a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective against HIV, Hepatitis C and Hepatitis B virus." The policy did not specify the need to ensure sufficient dwell time for use of disinfecting wipe or how sufficient dwell time would be achieved.
Review of CDC's website, at www.cdc.gov, section titled, "Infection Prevention During Blood Glucose Monitoring and Insulin Administration", showed that if the glucose meters must be shared, the device should be cleaned and disinfected after every use per the manufacturer's instructions.
Review of R4's record showed the facility admitted the resident on 6/16/18 with diagnoses including diabetes (A disease that makes the person more susceptible to developing infections, as high blood sugar levels can weaken the person's immune system defenses. In addition, some diabetes-related health issues, such as nerve damage and reduced blood flow to the extremities, increase the body's vulnerability to infection). R4's Minimum Data Set (MDS-assessment tool), dated 9/7/20, showed the resident received insulin.
Review of R5's record showed the facility admitted the resident on 12/18/19 with diagnoses including diabetes. R5's Minimum Data Set (MDS-assessment tool), dated 9/25/20, showed the resident received insulin.
Review of R6's record showed the facility admitted the resident on 7/13/19 with diagnoses including diabetes. R6's Minimum Data Set (MDS-assessment tool), dated 7/26/20, showed the resident received insulin.
2. Room and hand railings
During a concurrent interview and observation on 11/9/20 at about 9:30 AM Housekeeper (HK)1 placed cloth in bucket with liquid on top of cart and squeezed cloth of excess liquid and then used cloth to wipe down side rails in hallway on the first floor, near Room #40. The hallway hand rails were dry to touch and no longer visibly wet when touched after 28 seconds. HK1 again placed cloth in same bucket and then wiped nursing station counter on 1st floor and counter were no longer visibly wet with dry streaks visible when touched after 30 seconds. HK1 stated that solution in bucket was QT Plus. HK stated that she like to use QT Plus because it had less dwell time.
During a concurrent interview and observation on 11/9/20 at 9:59 AM HK1 entered Room #22 and placed cloth in bucket on housekeeping cart and then wiped resident's bed side rails, overbed table and window sill with cloth. Side rails were touched after 50 seconds and found to be dry and not wet. When asked if the side rails were wet or dry, HK1 stated that she could not remove gloves while in resident's room and therefore, could not tell if side rails were wet or dry. When asked what the QT Plus dwell time was, HK1 stated "5 minutes". When asked what dwell time meant, HK1 stated that it is the amount of time for it to be effective. When asked how HK ensured dwell time of 5 minutes was met or not, HK1 stated that she didn't know but was told by HK manager to squeeze cloth out (of liquid/QT Plus) and not keep too wet.
During concurrent interview and record review on 11/9/20 at 10:26 AM HK manager and surveyor reviewed label of QT Plus container (EPA number 6836-77) which showed solution must remain wet for 1 minute to be effective against the human coronavirus. When asked how staff ensured high touch items, hallway side rails or others disinfected with QT Plus remained wet for 1 minute, HK manager stated that it was a good question and didn't know. When asked if time studies or audits with timed testing were conducted, HK manager said "no" and shook her head. When asked if it was the expectation for staff to follow manufacturer's instructions for use of disinfectants, including dwell or contact time, HK manager said "absolutely" and stated that it is what is trained. Record review of facility document, "Extra Cleaning", undated, showed 16 different locations listed including handrails/door knobs, lifts, nurse station. HK manager stated that staff were doing extra cleaning of these areas due to COVID. Review of facility policy, Cleaning Procedures, dated 5/2008, showed the purpose was to maintain a clean environment but there was no reference to ensure disinfecting solutions manufacturer's instructions for dwell time were followed or how to ensure they were followed. HK manager reviewed policy and concurred this language was not present in the policy.
Observation on 11/9/20 on the 2nd floor at about 12:15 PM showed R9 self-propelling wheelchair towards the dining room area and grabbing onto hallway hand railings. R9 approached and held onto R10's hand as R10 was sitting in wheelchair outside Room #201. HK2 was cleaning Room #201 and then then exited room and placed cloth in bucket on housekeeping cart, then used cloth to wipe hallway hand railings on the 2nd floor. The same hand railings were touched after 19 seconds and found to be dry to touch.
Observation on 11/10/20 on the 2nd floor at 11:52 AM showed R11 holding onto hallway hand railing as she pushed herself in wheelchair down the hallway to the dining room.
Review of CDC Preparing for COVID-19 in Nursing Homes, https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, dated 6/25/20, accessed 11/17/20, under Environmental Cleaning and Disinfection showed "Develop a schedule for regular cleaning and disinfection of shared equipment, frequently touched surfaces in resident rooms and common areas; Ensure EPA-registered, hospital-grade disinfectants are available to allow for frequent cleaning of high-touch surfaces and shared resident care equipment ....Ensure HCP (healthcare personnel) are appropriately trained on its use."
3. Personal cares
Review of R7's record showed the facility admitted the resident on 9/5/19. R7's Minimum Data Set (MDS-assessment tool), dated 8/23/20, showed the resident was cognitively intact, needed assistance with toileting and had frequent incontinence of bladder.
Observations on 11/10/20 at about 11:30 AM showed Certified Nursing Assistant (CNA)1 assisted R7 to the bathroom. R7 stood up from her wheelchair and with gloved hands CNA1 pulled down resident's pants and briefs. R7 turned and sat on the toilet and urinated. CNA1 removed briefs which appeared to be wet. CNA1 discarded soiled brief in garbage. Using same gloved hands, CNA1 opened new package of briefs, placed several briefs on drawer near toilet and then placed new briefs on resident and then fastened briefs. R7 then stood up and CNA1 obtained a wipe and wiped R7's perineal area and then discarded in trash. There was no glove change. Using the same pair of gloves, CNA1 pulled up new brief and resident's pants and then doffed/removed gloves and wheeled and assisted resident transfer from wheelchair to recliner in her room. CNA1 then performed hand hygiene.
During an interview on 11/10/20 at 12:10 PM CNA1 stated that R7's brief was wet as resident is usually not able to fully get to the toilet in time. CNA1 stated that she should have changed her gloves after touching the soiled brief and before touching clean brief and finishing cares. CNA1 also stated that she should have also changed her gloves after wiping resident after she urinated in the toilet.
During an interview on 11/10/20 at 12:58 PM IP stated that staff are taught to segment tasks and change gloves between dirty and clean tasks. IP stated that there is a risk for contamination when staff do not change gloves when moving from dirty to clean tasks during incontinence care.
Review of the facility's policy titled, "Hand Hygiene," dated 1/1/1998, showed use of an alcohol-based hand rub for several situations including after contact with body fluids or excretions and when moving from a contaminated body site to a clean body site during a resident care.
The Center for Disease Control and Prevention, "Guidelines for Hand Hygiene in
Healthcare Settings," dated October 2002, showed "hand hygiene is required regardless of whether gloves are used or changed. Failure to remove gloves after patient contact or between "dirty" and "clean" body-site care on the same patient must be regarded as nonadherence to hand-hygiene recommendations."
4. Cloth face coverings
Observation on 11/9/20 at 11:35 AM showed 3 residents sitting in front of large tv room on the 2nd floor. None of the residents had cloth face coverings. The residents were more than six feet apart. R1 had a "Do not enter" banner across the entrance of her door.
Observation on 11/9/20 at 12:00 PM showed 6 residents in dining room area on the 2nd floor. None of the residents had cloth face coverings. The residents were more than six feet apart.
During continuous observation on 11/9/20 on the 2nd floor at about 12:15 PM showed R9 self-propelling wheelchair towards the dining room area. R9 approached and held onto R10's hand as R10 was sitting in wheelchair outside Room #201. R9 and R10 did not have cloth face covering and were within arms-length of each other; less than 2 feet apart. Staff brought additional residents into the dining room. By 12:23 PM there were 11 residents in the dining room with none of the residents wearing cloth face coverings. Each resident was at a separate dining room table more than six feet apart. R12 started coughing, it was a moist productive sounding cough. The resident coughed into her fist. Cough etiquette was not observed. CNA1 and CNA3 began placing utensils on resident tables. At about 12:28 PM, meals were served to residents. For almost 30 minutes, prior to meals being served, residents were in the dining room area not wearing cloth facing coverings. Cloth face coverings were not observed on any of the resident's wheelchairs, table, persons, or vicinity.
During interview on 11/10/20 at 9:19 AM IP stated residents should be wearing face coverings when out of the room, when shared observation about residents on the 2nd floor not wearing face coverings, IP stated she was told residents won't keep them on and RCM developed a care plan for face coverings.
Observation on 11/10/20 at 11:13 AM showed 3 residents in tv area on the 2nd floor. None of the residents had cloth face coverings. The residents were in wheelchairs more than 6 feet apart. R7 had a "Do not enter" banner across the entrance of her door.
Record review of Roster for NC 11/8/20 Sequence by Unit Location + Census Status-Admitted, dated 11/9/20, showed 19 residents resided on the 2nd floor.
During an interview on 11/10/20 at 11:54 PM Resident Care Manager (RCM)1 stated that most of the residents on the 2nd floor had cognitive difficulties. Four residents on the 2nd floor were alert and oriented (R7, R8, R1 and R13). Some residents like coming out of their room for breakfast, most came out of their room for lunch, and staff do pretty good about keeping residents 6 feet apart. RCM1 further stated that some residents don't like being in their room and for the mental health piece, they like to be out of their room. Some residents, such as R11, R13, R14, were wanderers and self-propel themselves in their wheelchair. When asked about the "Do not enter" banners across the entrance to R1 and R7's rooms, RCM1 stated that this is to prevent R14 who was a wanderer, self-propels in wheelchair, and uses hallway hand rails, from entering rooms. RCM1 stated that all residents should have a mask (face coverings) in their rooms, but we can't make them wear it, we encourage residents to wear their masks. When asked about R3's care plan for staff encouraging mask use, RCM1 showed psychosocial care plan that stated that resident may not tolerate wearing mask, encourage resident to wear mask during cares, respect choice not to.
Observation on 11/10/20 at 12:10 PM showed R8 sitting alone at a table in the dining room. R8 was not wearing cloth face covering/mask. When asked about mask, R8 stated, "I have a mask, somewhere in my room. Sometimes I wear it, sometimes I don't." When asked if staff reminds her to wear a mask when out of her room, R8 stated "no, never." When asked, resident recalled correctly that surveyor had observed and consented to observation of her COVID testing earlier in the day.
Review of R8's record showed the facility admitted the resident on 6/23/18. R8's Minimum Data Set (MDS-assessment tool), dated 9/30/20, showed the resident was cognitively intact.
During interview on 11/10/20 at about 12:30 when asked if residents should be wearing face coverings when out of their room, Administrator stated, "yes". When observations shared of multiple residents on the 2nd floor not wearing cloth face coverings during two separate days, staff not heard reminding/encouraging residents to wear cloth face coverings, no cloth face coverings observed on resident's wheelchair, table, persons, or vicinity and unit has several residents who wander and self-propel not adhering to six feet social physical distance and both residents and staff in the facility had been COVID positive, Administrator nodded head in agreement about concerns regarding lack of cloth face covering and need for staff to encourage/remind residents about using cloth face coverings.
Review of CDC Preparing for COVID-19 in Nursing Homes, https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, dated 6/25/20, accessed 11/17/20, showed "Implement aggressive social distancing measures (remaining at least 6 feet apart from others). Remind residents to practice social distancing, wear a cloth face covering (if tolerated) ...."
Review of CDC Considerations for Wearing Masks, https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cloth-face-cover-guidance.html, updated 11/12/20, accessed 11/17/20, showed "A mask is NOT a substitute for social distancing. Masks should still be worn in addition to staying at least 6 feet apart."
5. Face shields
Observation on 11/9/20 at about 10:30 AM showed CNA2 enter R15's room. CNA2's face shield was not covering the sides of her face as the face shield was tilted upwards at a 45 degree angle from the vertical. The bottom of the face shield was not flush with the user's chin. The door of R15's room had a sign showing Droplet and Contact Precautions (mask, eye protection; such as face shield, gown and gloves were required), isolation cart was outside the room, there was also a paper was on the cart that asked staff to list their name if they entered the room.
Observation on 11/9/20 at about 12:15 PM showed CNA3 in the 2nd floor dining room. The top of CNA3's face shield was high on her forehead, near or above her hairline and tilted at angle, thereby the face shield was not covering the sides of her face, including the sides of her eyes.
During a concurrent observation and interview on 11/10/20 at 8:09 AM showed CNA3 in the 2nd floor dining room with about 7 residents sitting at different tables. The top of CNA3's face shield was positioned high on her forehead, near or above her hairline and tilted upwards, thereby the face shield was not covering the sides of her face or sides of her eyes. When asked if splashes or sprays came towards the side of her face, near her eyes, if her eyes would be covered and protected from the face shield, CNA3 said "no" and stated that she understood that face shield should be protecting the front and sides of her eyes.
Record review of Roster for NC 11/8/20 Sequence by Unit Location + Census Status-Admitted, dated 11/9/20, showed R15 was admitted to the facility on 11/4/20.
During an interview on 11/9/20 at 8:20 AM Administrator stated that the residents who were in transmission based precautions required full PPE.
Review of facility policy, Using Personal Protective Equipment (PPE), dated 3/16/2018, showed goggles/face shield: put over face and eyes and adjust to fit. The purpose of PPE use was to avoid cross contamination by using safe practices to protect yourself and limit the spread of infection.
Review of CDC Preparing for COVID-19 in Nursing Homes, https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, dated 6/25/20, accessed 11/17/20, showed "eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face)."
Review of CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Finfection-control%2Fcontrol-recommendations.html, updated 11/4/20, accessed 11/17/20, showed "Put on eye protection (i.e., goggles or a face shield that covers the front and sides of the face) upon entry to the patient room or care area, if not already wearing as part of extended use strategies to optimize PPE supply .....gaps between glasses and the face likely do not protect eyes from all splashes and sprays."
F880Please note the facility currently remains COVID free.1. GlucometerCorrection of deficiency for cited residentsResident 4 – The resident has no evidence of infection related to the observed deficient practice. The procedure has been updated to ensure professional standards are followed and licensed nurses educated. Please see our plan of correction below for further information.Resident 5 – The resident has no evidence of infection related to the observed deficient practice. The procedure has been updated to ensure professional standards are followed and licensed nurses educated. Please see our plan of correction below for further information.Resident 6 – The resident has no evidence of infection related to the observed deficient practice. The procedure has been updated to ensure professional standards are followed and licensed nurses educated. Please see our plan of correction below for further information.How facility will act to protect residents in similar situationsAll residents receiving CBG testing are at risk related to the observed deficient practice. Each resident now has their own CBG testing equipment. These residents, as well as all residents are currently being monitored for signs of infections. There have been no observed signs of infection. Please see our plan of correction below.Measures implementedThe facility has obtained individual glucometer (CBG Testing) equipment for all residents requiring such testing. Each glucometer is stored separately in plastic bags on the medication cart. A new procedure has been developed where after use, the glucometer is wrapped in a Super Sani-cloth and stored in a plastic cup to ensure adequate dwell time per manufacturer’s guidance, then dried and placed back in the storage bag. Policies and procedures have been updated to include the new procedure as well as information relating to dwell times. Licensed Nurses have been educated prior to compliance date by our Infection Preventionist and Director of Nursing; and have had competency testing. MonitoringMonitoring will include educating and observing competency on hire and a minimum of annually. Our expectation is 100% compliance with the procedure we have implemented. Therefore, we are currently conducting random observations of the task with our licensed nurses and will continue until compliance date to ensure full compliance. Responsible PersonJoanne Beaver RN, IPCompliance DateJanuary 1, 20212. Room and handrail cleaningCorrection of deficiency for cited residentsResident 9 – We have implemented new cleaning procedures that include ensuring sufficient dwell time and observation to ensure no resident holds the handrail until the cleaning procedure is complete. This resident has no evidence of an infection at this time; we continue to monitor this resident. Please see our plan of correction below.Resident 10 – The is no evidence of an infection at this time that could be related to the observation of resident 9 and 10 holding hands. We continue to monitor this resident. Please see our plan of correction below.Resident 11 – We have implemented new cleaning procedures that include ensuring sufficient dwell time and observation to ensure no resident holds the handrail until the cleaning procedure is complete. This resident has no evidence of an infection at this time; we continue to monitor this resident. Please see our plan of correction below.How facility will act to protect residents in similar situationsAll residents will be considered at risk related to this citation. We have implemented new procedures, please see our plan of correction below.Measures implementedWe have updated our cleaning procedures to ensure a procedure for cleaning that will provide for adequate dwell time per manufacturer’s guidance when cleaning resident rooms, handrails and other procedures. The procedure includes steps for cleaning and ensuring dwell time prior to a resident touching the surface(s). All staff responsible for cleaning have been educated by our Housekeeping Director on the steps for the new procedure(s) prior to compliance date and competency tested. In addition, the facility has implemented infection control rounds that will occur on random shifts.MonitoringMonitoring will include educating and observing competency on hire and a minimum of annually. Our expectation is 100% compliance with the procedure we have implemented. Therefore, we are currently conducting random observations of the task and will continue until compliance date to ensure full compliance. Responsible PersonDave Detweiler Facilities Director Compliance DateJanuary 1, 20213. Personal CaresCorrection of deficiency for cited residentsResident 7 – The care plan has been updated to instruct staff to provide peri care in keeping with infection control standards of practice. Please also see our plan of correction.How facility will act to protect residents in similar situationsAll residents are considered at risk related to the surveyor observation. We have updated our personal care procedures to reflect the CDC guidance related to hand hygiene and glove use. Please see our plan of correction below.Measures implementedWe have updated our personal care procedures to ensure they reflect the CDC guidance related to hand hygiene and glove use. These updated procedures include guidance for glove use and hygiene after resident contact and removal of gloves between “dirty” and “clean” body-site care. All department specific staff have been provided education by our department heads on these new procedures prior to compliance date and competency tested.MonitoringSpecific monitoring tools have been developed in order to observe staff competencies relating to mask use, hand hygiene and glove use that follow CDC recommended procedures. We are currently monitoring various tasks with random procedures and staff weekly over the next month. At a minimum, competency in these areas will occur on hire and annually. Our general infection prevention and control program include process surveillance when we exceed a threshold in our overall rate or specific infections. Surveillance is monthly and process surveillance using these newly developed tools will be utilized to understand why a threshold was not met. Responsible PersonAngela Trahan Director of Nursing Compliance DateJanuary 1, 20214. Cloth Face CoveringsCorrection of deficiency for cited residentsResident 1 and 7 – “Do not enter” signs continue to be placed at these resident’s door entries.Resident 9 – This resident has no evidence of an infection at this time; we continue to monitor this resident. Please see our plan of correction below.Resident 10 – There is no evidence of an infection at this time that could be related to the observation of resident 9 and 10 holding hands. We continue to monitor this resident. Please see our plan of correction below.Residents 11, 13 and 14 – Care plans address wandering and interventions to maintain resident safety. These residents currently how no evidence of an infection.Resident 12 – We are updating this resident’s care plan for staff to provide hand hygiene when they witness the resident coughing into their hands. There is no evidence of an infection at this time that could be related to the observation as cited in the survey.Resident 3 – The care plan continues to contain an intervention to encourage mask use.How facility will act to protect residents in similar situationsAll residents could potential be affected by this citation. We are updating all care plans to ensure staff encourage mask use when the residents are out of their rooms and staff have received education.Measures implementedAll floors now have a supply of masks openly available for staff to encourage resident mask use. Nursing staff have been educated by the Infection Preventionist and Director of Nursing on their roles and responsibilities to encourage mask use when the resident is out of their room as per care plan interventions and to honor the residents’ right to refuse while attempting as possible to maintain COVID protocols of social distancing and hand hygiene. This will be documented in the treatment record once a shift.MonitoringThe facility has implemented infection control rounds that will occur on random shifts in order to identify issues related to resident, staff or environmental infection control deficiencies.Responsible PersonJoanne Beaver, RN, IP Compliance DateJanuary 1, 20215. Face ShieldsCorrection of deficiency for cited residentsResident 15 – There is no evidence of an infection at this time that could be related to the observation as cited in the survey. We continue to monitor this resident. Please see our plan of correction below.How facility will act to protect residents in similar situationsAll residents will be considered at risk related to this citation. We currently do not have any residents or staff with positive COVID. Please see our plan of correction below.Measures implementedWe are implementing new face shields that provide better coverage. Staff have been educated by our Infection Preventionist and Director of Nursing related to the use of face shields and the importance covering the front and sides of the face.MonitoringSpecific monitoring tools have been developed in order to observe staff competencies relating to mask use, hand hygiene and glove use that follow CDC recommended procedures. We are currently monitoring various tasks with random procedures and staff weekly over the next month. At a minimum, competency in these areas will occur on hire and annually. Our general infection prevention and control program include process surveillance when we exceed a threshold in our overall rate or specific infections. Surveillance is monthly and process surveillance using these newly developed tools will be utilized to understand why a threshold was not met. In addition, the facility has implemented infection control rounds that will occur on random shifts in order to identify issues related to resident, staff or environmental infection control deficiencies.Responsible PersonAngela Trahan DNS Compliance DateJanuary 1, 2021
