A COVID-19 Focused Infection Control Survey was conducted by the Oregon State Survey Agency on 12/2/20 through 12/3/20.
Deficiency was cited.
Total residents: 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: 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 1/25/21 through 2/2/21.
The facility was found to be in compliance with 42 CFR 483.80.
Total residents: 21
Based on interview and record review it was determined the facility failed to report a positive COVID-19 test in a timely manner for 1 of 21 (#1) residents reviewed for COVID-19 testing results. This placed residents at risk for COVID-19. Findings include:
Resident 1 was admitted to the facility 11/2020 with diagnoses including heart disease.
A review of the facility's COVID-19 testing logbooks revealed every resident who resided at the facility was tested for COVID-19 on 11/20/20 and Resident 1 was the only COVID-19 positive result.
On 12/2/20 at 12:00 PM Staff 4 (Infection Preventionalist, IP) said one facility resident had a positive COVID-19 test result on 11/20/20 and she thought Staff 2 (DNS) had reported the result to the State Agency. Staff 4 indicated on 11/30/20 she became aware Resident 1's COVID-19 test result was not reported to the State Agency until 11/30/20.
On 12/2/20 at 12:15 PM Staff 2 (DNS) said Staff 4 (IP) worked part-time as the facility's IP and she thought Staff 4 reported the resident's positive COVID-19 test to the appropriate State Agency. She stated she was out of the office during the week of 11/23/20, returned to work on 11/30/20, it came to her attention the facility had not reported Resident 1's positive COVID-19 test result to the State Agency and she did so on 11/30/20. Staff 2 acknowledged the facility did not ensure Resident 1's positive COVID-19 test result was reported in a timely fashion to the State Agency.
It is the intent of the facility to meet regulatory requirements for F880.As stated in the SOD, the positive Resident test result was reported on 11-30-20 upon DNS becoming aware that it had not been reported by the IP Nurse on 11-20-20.No other LTC Residents have been affected by this deficient practice as none have been positive for COVID-19 per facility POC testing per CMS/CDC guidelines. In the event that a Resident tests positive for COVID-19 in the future, the following measures are now in place:EDUCATION1)Staff 2-DNS has reviewed all current applicable OHA/DHS/CMS/CDC/NHSN COVID-19 test result reporting requirements to local, State, and Federal agencies as above related to positive test results, and has assumed responsibility for any future need to report positive results. Staff 2-DNS as well as Designee Mary Margaret Shults RN, have set up electronic automatic notifications for updates to these reporting requirements as well as other COVID-19 related information from DHS, OHA, CMS, and CDC to ensure changes in requirements, if any arise, are not overlooked. An on-line query/review will also be done weekly by the DNS and Designee to ensure no new information has been overlooked.REPORTING2)Positive test results will be reported by the DNS to DHS/OHA immediately via the NF Licensing web site.3)In the absence of the DNS, Mary Margaret Shults RN will ensure that any positive test result will be reported immediately to DHS/OHA via the above website as well as to the IP Nurse.AUDITS/QA REVIEWS4)Upon email notification to the State, a copy of the notification and the confirmation of receipt of that notification will be retained by the DNS for verification/review QA purposes. 5)A copy of the notification to DHS/OHA will also be sent to the LNHA, and the Medical Director.6)All Resident testing results (if testing has taken place)will be reviewed weekly to ensure compliance with reporting of positive results at the facility weekly QA/Risk Meeting, and with the facility IP weekly for NHSN reporting purposes. 7)All positive Resident testing data and reporting will be reviewed at quarterly QAPI meetings. These weekly and quarterly audits/reviews for compliance will continue on an ongoing basis unless/until this reporting requirement changes or ends.
A COVID-19 Focused Infection Control Survey was conducted by the Oregon State Survey Agency on 12/2/20 through 12/3/20.
Deficiency was cited.
Total residents: 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: 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 from 1/25/21 through 2/2/21.
The facility was found to be in compliance.
Total residents: 21
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OAR 411-086-0330 Infection Control and Universal Precautions
Refer to F880
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