A COVID-19 Focused Emergency Preparedness Survey was conducted by the Oregon State Survey Agency from 2/24/21 to 3/3/21. The facility was found to be in compliance with 42 CFR 483.73 related to E-0024 (b) (6).
Total residents: 64
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Oregon State Survey Agency 4/22/21. The facility was found to be in compliance with 42 CFR 483.73 related to E-0024 (b) (6).
Total residents: 64
The findings of the complaint (Intake #s 25332 and 28099) and COVID-19 Focused Infection Control health survey conducted 2/24/21 through 3/3/21 are documented in this report. The survey was conducted to determine compliance with 42 CFR Part §483 Requirements for Long Term Care Facilities.
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 recertification and complaint (Intake #s 25332 and 28099) health revisit survey conducted 4/22/21 are documented in this report. The facility was found to be in substantial compliance with 42 CFR Part §483 Requirements for Long Term Care Facilities.
Based on observation, interview and record review it was determined the facility failed to implement and maintain an effective Infection Control Program related to handling and storage of eye protection (face shields or goggles), the use of Aerosol Generating Procedures (AGPs) and resident monitoring based on CDC guidelines and acceptable standards of practice for COVID-19. This placed residents at risk for facility-transmitted infections. Findings include:
1. According to CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19 Pandemic:
Extended use of eye protection-
"Eye protection should be dedicated to one healthcare personnel (HCP) and cleaned and disinfected if it becomes visibly soiled or removed. Once fully dried, eye protection can be stored onsite in a designated clean area within the facility."
On 2/24/21 at 11:30 AM upon entrance to the facility, there was no observed face shield storage area. Staff 6 (Screener) was asked where staff stored their face shields when not in use. Staff 6 stated face shields were not stored, staff took them with them out of the facility but they could get a new face shield if desired.
On 2/24/21 at 1:40 PM a staff member entered the facility wearing a face shield from outside.
On 2/25/21 at 9:45 AM a staff member walked from inside the facility to the front entrance, announced she was going out to her car to get something and would be right back. She proceeded out the front door wearing both her N95 mask and face shield. Approximately three minutes later returned wearing a N95 mask and face shield and did not change her N95 mask or disinfect her face shield.
On 2/25/21 at 11:13 AM an unlabeled face shield was observed on a bare table in the staff breakroom. There was no staff in the general area and no observed area for staff to disinfect their face shield while on break.
On 2/25/21 at 12:58 PM Staff 8 (LPN) was asked about handling and storage of her face shield and Staff 8 stated she took her face shield home with her after her shift.
In an interview on 2/25/21 at 2:00 PM face shield handling was discussed with Staff 1 (DNS). Staff 1 stated the facility changed how they handled their face shields and currently staff were to dispose of their face shields at the end of each shift. Staff 1 added the facility was considering creating a face shield storage area.
2. According to CDC's guidelines:
"Aerosol Generating Procedures (AGPs) have been associated with an increased risk for transmission in healthcare settings. Facilitate private rooms for all residents utilizing AGPs as able.
a. During an aerosol generating procedure implement the following procedure.
i. Only one staff member present during the procedure.
ii. Door closed during the procedure and for two hours afterwards unless the facility's air exchange rate is known.
iii. Include signage on the door that clearly states when the door may be opened, and staff can resume normal PPE use.
b. Staff should use full PPE including an N95 mask during the procedure or anytime they enter the room during the procedure.
c. PPE should be discarded after each encounter and eye protection disinfected per acceptable standards of practice."
2. A review of the facility policy for AGPs indicated a room door was to remain closed for 30 minutes following a procedure.
On 2/24/21 at 2:45 PM Staff 9 (LPN) was asked about AGPs and she stated she was not aware of any specific instructions related to handling of CPAPs (a device used to help a person breathe easier during sleep).
On 2/25/21 at 11:13 AM Staff 7 (LPN) was asked about AGPs for Resident 3 and stated she/he was capable of donning and doffing her/his CPAP independently. Staff 7 added the policy was to keep the door closed for 30 minutes after the procedure but they could not always keep the door closed due to safety reasons. Staff 7 stated the facility did not use signs to indicate a treatment was in progress or completed.
On 2/25/21 at 12:58 PM Staff 8 (LPN) was asked about residents receiving AGPs and she stated she had a resident who used a CPAP and was capable of removing it on her/his own. Staff 8 added the resident slept with her/his door closed and the door should remain closed for 30 minutes following the treatment. Staff 8 said they did not use signs to alert staff a CPAP was in use.
On 3/3/21 at 10:30 AM AGPs were discussed with Staff 1 (DNS) and Staff 10 (Administrator). Staff 1 stated they implemented the current national standards of practice for AGPs on 2/25/21.
3. According to CDC's guidelines:
"Actively monitor all residents upon admission and at least daily for fever and symptoms consistent with COVID-19. Identification of symptoms should prompt isolation and further evaluation for COVID-19."
Records were reviewed for Resident 3 which included vital signs. The records did not indicate symptoms of COVID-19 were being monitored.
On 2/24/21 at 2:00 PM symptom monitoring was discussed with Staff 1 (DNS) who stated they did not monitor symptoms for COVID-19 negative residents.
In an interview on 3/3/21 at 10:30 AM Staff 1 (DNS) stated the facility implemented monitoring of symptoms for all residents after 2/25/21.
Corrective Action Face shields will be cleaned and stored in a dedicated clean area within the facility when not in use. Doors will remain closed during the aerosolizing procedures and for 2 hours after procedure completed. Signs will be placed on the resident door to identify that door is to remain closed during procedure and 2 hours after. Full PPE, including N95 masks will be used when entering resident’s room during this time period. Active monitoring will be completed on all residents and documented in PCC on Active Monitoring Record. Identification others at risks ADM/designee will complete baseline audit to verify that face shields are being stored in a clean area in the facility when not in use. DON/Designee will complete baseline audit to verify that door is kept closed during aerosolizing procedures and for 2 hours after procedure. Baseline audit will be completed on staff utilization of full PPE when entering rooms during/after aerosolizing procedures. DON/Designee will complete baseline audit to verify that active monitoring is documented in PCC on Active Monitoring Record. Newly identified concerns will be addressed: Systemic Changes DON/designee will initiate training on 3/22/21 related to face shield storage for facility staff. DON/designee will initiate training on 3/22/21 related to aerosolizing procedures, PPE use and active resident monitoring for nursing staff. Include content and sign-in sheets for education Monitoring for compliance ADM/designee will audit weekly x4, monthly x3 to validate that face shields are being stored in dedicated clean area in facility when not in use. DON/designee will audit weekly x4, monthly x3 to validate that doors are kept closed during aerosolizing procedures and for 2 hours after procedure. Audit will also be done to validate that full PPE is being worn when staff enter room during and 2 hour post aerosolizing procedure. DON/designee will audit weekly x4, monthly x3 to validate that active monitoring is completed and documented on PCC Active Monitoring record. DON/designee will analyze audits and results will be reported to the QAPI committee for review and recommendations monthly.
The findings of the licensure and complaint (Intake #s 25332 and 28099) health survey conducted 2/24/21 through 3/3/21 are documented in this report. The survey was conducted to determine compliance with OAR 411 - 85 through 89. For additional information refer to the Form CMS 2567 dated 3/3/21.
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
The findings of the licensure and complaint (Intake #s 25332 and 28099) health survey conducted 4/22/21 are documented in this report. It was determined the facility was in substantial compliance with OAR 411 - 85 through 89.
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OAR 411-086-0330 Infection Control and Universal Precautions
Refer to F 880.
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