A COVID-19 Focused Infection Control Survey was conducted by the Oregon State Survey Agency on 11/19/20 to 11/20/20.
Deficiencies were cited.
Total residents: 48
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 1/26/21 to 1/26/21.
The facility was found to be in compliance with 42 CFR ยง483.80.
Total residents: 40
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 a shared glucometer (a medical device for measuring blood sugar levels) for 2 of 2 sampled residents (#s 2 and 4) observed for blood sugar level monitoring. In addition, during both glucometer observations, staff did not use a barrier to protect the used glucometer from contaminating the resident room environment and a treatment cart. These failures increased the risk for the spread of infection and its associated discomfort and decline in physical condition. Findings include:
A 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.
The Centers for Disease Control and Prevention (CDC)'s Guidelines for Environmental Infection Control in Health-Care Facilities, updated July 2019, accessed 11/19/20, https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html, showed "Recommendations-Environmental Services ...Cleaning and Disinfecting Strategies for Environmental Surfaces in Patient-Care Areas," " ...use barrier protective coverings as appropriate for noncritical equipment surfaces that are touched frequently with gloved hands during the delivery of patient care; likely to become contaminated with blood or body substances ...."
A review of the PDI Super Sani-Cloth (disinfectant wipes) container 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."
The facility's policy and procedure Disinfection of Point-of-Care Devices/Instrument revised 04/19 indicated all point-of-care devices, such as glucometers, would be cleaned and disinfected according to manufacturer's recommendation using EPA approved disinfectant.
During a concurrent observation on 11/19/20 at 11:29 AM showed Staff 4 (RN) to enter Resident 2's room with Assure Platinum glucometer (Glucometer is a blood glucose meter device that measures blood glucose levels). At 11:32 AM Staff 4 returned to the treatment cart and placed the used glucometer directly on the treatment cart without immediately disinfecting it or placing a barrier between the glucometer and the cart. Staff 4 then proceeded to pass medications. Staff 4 verified he did not disinfect the glucometer after it was used to test Resident 2's CBG (capillary blood glucose) and stated he was going to do it later. Staff 4 donned gloves and used Super Sani-Cloth wipes to wipe the glucometer for several seconds in a hurried manner and within 30 seconds placed the glucometer in the treatment cart drawer.
An observation on 11/19/20 at 12:03 PM showed Staff 4 to enter Resident 4's room with Assure Platinum glucometer, lancet, alcohol swab, and test strip. Staff 4 placed the glucometer and other supplies directly on the resident's overbed table. No barrier was used to protect the glucometer. Staff 4 donned gloves and placed the test strip into the glucometer, swab the resident's finger with alcohol and then pricked a finger with the lancet with a small bead of blood shown. Staff 4 brought the glucometer towards the blood and blood was shown on the test strip inserted in glucometer. A blood sugar reading was obtained. Staff 4 exited the room and placed the used glucometer directly on the treatment cart with no barrier used to protect the treatment cart. Staff 4 donned gloves and pulled out Super Sani-Cloth wipes and wiped the glucometer briefly. The glucometer was dry to touch when touched at 45 seconds after the start of disinfecting wipes use.
During an interview on 11/19/20 at 12:05 PM when asked about the dwell time for use of disinfecting wipes on glucometer, Staff 4 stated "30 seconds". Staff 4 then looked at the disinfecting wipes container and stated, "It says 2 minutes, I guess I should have done it for 2 minutes."
During an interview on 11/19/20 at 12:15 PM Staff 5 (DNS) was asked about the correct procedure staff were to follow when disinfecting a glucometer. Staff 5 demonstrated the use of Super Sani-Cloth wipes to disinfect a small timer in a similar manner to how Staff 4 was observed to disinfect the glucometer. Staff 5 verified Super Sani-Cloth wipes had a two minute dwell time and the timer she disinfected did not remain wet for two minutes.
2. Failed to clean and disinfect high touch surfaces in 2 of 2 sampled resident rooms (#s 27 and 34) observed for housekeeping services. These failures increased the risk for the spread of infection and its associated discomfort and decline in physical condition. Findings include:
A 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 11/19/20, 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."
A review of Environmental Protection Agency (EPA) N-List, https://cfpub.epa.gov/giwiz/disinfectants/index.cfm, accessed 11/19/20, showed a contact time of 10 minutes for product with Environmental Protection Agency (EPA) registration number of 1839-169.
The facility's policy, Daily Resident Room Cleaning Policy, dated 1/19/19, showed all residents rooms will be ...cleaned daily. "Horizontal surfaces-disinfected included table tops, head board, window sill, chairs-should all be done."
An observation on 11/19/20 at 11:27 AM showed Staff 6 (Housekeeper) entered Room #27 (Resident 5's) room. Staff 6 donned gloves and grabbed a cloth from the bucket with liquid on the housekeeping cart and then used the cloth to wipe the top surface of the overbed table and window sill. Staff 6 discarded the used cloth. Staff 6 grabbed another cloth from the same bucket and wiped another overbed table. Staff 6 then bagged trashed, swept and mopped room. Staff 6 placed wet floor sign outside room entrance.
An observation on 11/19/20 at 12:11 PM showed Staff 6 entered Room 34 which was occupied by Resident 6 and Resident 7. Staff 6 donned gloves and grabbed a cloth from the bucket with liquid on the housekeeping cart and then used the cloth to wipe the top surface of Resident 7's overbed table. Staff 6 obtained a new cloth from the bucket and wiped the top surface and stand of Resident 6's overbed table. Staff 6 bagged trash, swept and mopped floor and then placed wet floor sign outside room entrance.
A concurrent observation and interview on 11/19/20 at 12:15 PM showed Resident 7 with TV on. When asked, the resident stated she/he used her/his call light and pointed to the location of the call light which was pinned near her/his bed. The resident also stated she/he used the TV remote control and also the bed controls. Resident 7 had mobility bars on the bed.
An observation on 11/19/20 at 12:16 PM showed Resident 6 sitting in wheelchair near bed with the call light cord wrapped around her/his wheelchair. The resident had mobility bars on the bed.
During an interview on 11/19/20 at 12:24 PM Staff 6 stated that she finished cleaning Resident 6 and Resident 7's room. Interview was limited due to language barrier between surveyor and Staff 6.
During an interview on 11/19/20 at 12:33 PM Staff 7 (CNA) stated that housekeeping was responsible for cleaning resident rooms. When asked if nursing staff cleaned resident mobility bars, remote controls, call lights, bed controls or other items in resident rooms, Staff 7 shook her head and said, "no".
During an interview on 11/19/20 at 12:44 PM Staff 8 (Maintenance Supervisor) stated the liquid container on the housekeeping cart is HCQB C2 solution. Staff 8 stated HCQB C2 solution had a contact time of 10 minutes. Surveyor reviewed the label of HCQB C2 container (EPA number 1839-169) but contact time was not shown. When asked about expectations for housekeeping daily resident room cleaning, Staff 8 stated high touch items should be cleaned with Pure solution by spraying the solution directly onto items and then wiping them down. When asked for examples of high touch items, Staff 8 stated, "bed rails, TV remote control, hallway hand railings." When asked for an orientation checklist or room observation audit forms, Staff 8 stated that this was not necessary because the housekeeping staff had worked in the facility for over 10 years. When informed of observations that only the overbed table was cleaned with HCQB C2 solution and 10 minute contact time was not observed and no cleaning was observed for the three residents' bed mobility bars, TV remote control, bed control and call light, Staff 8 confirmed the high touch items in the resident rooms were not cleaned/disinfected and was not done the way it should have been performed.
POC Infection Control Survey - Forest GroveAlleged Compliance Date 01/08/2021F 880The facility does and will continue to 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.1).a). Licensed Nurse (staff #4) has been in-serviced on proper dwell time for the use of Sani-cloths to clean glucometers between resident use. Licensed Nurse (staff #4) was retrained on use of barrier with glucometer to prevent contamination in resident room environment and treatment care. Resident #2 and Resident #4 were assessed and had not negative outcome from this action. b). Resident room #27 and #34 have been cleaned - including top surfaces of overbid table, and wine sills, and all high touch areas have been and continue to be cleaned per policy. Residents #5, 6 and 7 had no negative outcomes as a result of the housekeeper incomplete cleaning of the rooms. Resident #6 and 7 also had call light buttons, mobility bars and TV remotes cleaned and continue to be cleaned. Housekeeper (staff #6) has been in-serviced on policy regarding cleaning of resident rooms, high touch cleaning and use of Pure, including but not limited to over-bed tables. Mobility bars, TV remote controls, bed controls, call bells. She was also in-serviced on dwell times for floor cleaner and high touch cleaning areas.Maintenance Supervisor (staff #8) was in-serviced on orientation, audit tools and rounding for monitoring environment, room cleaning policy and oversight, and oversight of EVS staff for dwell times. 2) a). All residents with Glucometer use have been assessed to ensure there were no negative outcomes from improper use of glucometer. b). All resident rooms have been cleaned, and special focus on high touch surfaces, no negative outcomes from this episode. 3). a). Licensed nurses have been in-serviced on proper glucometer cleaning and dwell times of cleaner and use of paper towel or cup for barrier between glucometer and surfaces. Infection Control support visit by OHA was completed on 12-14-2020 with our DNS. b). Housekeepers have been in-serviced on room cleaning policy, dwell times for floor and high touch cleaners, and cleaning of high touch areas. 4). a). Random observations and audits of LN cleaning and using glucometers will be completed weekly for 4 weeks, and then monthly thereafter until compliance is reached. Findings will be presented to QA Committee for oversight and compliance.b). Random observations and audits will be completed of cleaning of residents rooms and high touch areas, weekly for 4 weeks (starting week of 12-14-2020) and monthly thereafter for 2 more months. Findings will be presented to QA Committee for oversight and compliance. 5). A). DNS responsible for overall compliance B). Administrator responsible for overall compliance
Based on interview and record review, it was determined the facility failed to inform residents, their representatives and families of cumulative updates of COVID-19 in the facility. This failure affected all 48 residents in the facility and deprived residents, their representatives or families from being informed of the extent of COVID-19 cases in the facility. Findings include:
During an interview on 11/19/20 at 2:10 PM Staff 9 (Social Services Director) stated she notified resident, representatives and family members when the facility had COVID positive resident and staff. Notification occurred via letter email and a copy of the letter was given to each resident in the facility. Staff 9 stated she would provide the last 3-4 letters sent. Staff 9 stated notifications were not conducted via website updates.
A review of the three most recent update letters dated 11/5/20, 11/7/20 and 11/14/20 revealed no cumulative update was included for the current facility COVID outbreak.
On 11/19/20 at approximately 2:30 PM during an interview with Staff 5 (DNS) and Staff 10 (Administrator) verified the letters were not cumulative and indicated the format would be modified to provide cumulative updates.
F885The facility does will continue to Inform residents, their representatives, and families of those residing in facilities by 5 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other.1). Social Services (staff 9) was in-serviced that all letters must include the cumulative number. Marketing was spoken to by the Administrator to update the format to include cumulative numbers.2) Marketing updated the letter format include a table that specifically includes the Total. Total issued in replace of the word cumulative for ease of understanding.3). All letters are now reviewed by RSN prior to being emailed out for auditing and oversight. 4). Findings will be reported to QA committee for oversight for 3 months. 5). Administrator is responsible for overall compliance.
A COVID-19 Infection Control Survey and a COVID-19 Confirmed Facility Review were conducted by the Oregon State Survey Agency on 11/19/20 to 11/20/20.
Total residents: 48
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
A COVID-19 Confirmed Facility Review was conducted by the Oregon State Survey Agency on 1/26/20 to 1/26/20.
Total residents: 40
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OAR 411-086-0130 Nursing Services: Notification
Refer to F885
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OAR 411-086-0330 Infection Control & Universal Precautions
Refer to F880
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