A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) December 8, 2020 onsite at Friendship Health Center..
The facility was found to be in substantial compliance with 42CFR §483.73 related to E-0024 (b) (6).
Facility Census: 61 Resident Sample: 7
CMS surveyor: #29087
Federal Surveyors can be reached at:
US Department of Health and Human Services
Centers for Medicare and Medicaid Services
701 Fifth Avenue Suite 1600
Mailstop 400
Seattle, WA 98104
206.615.2313
A COVID-19 Focused Infection Control Survey was conducted by the Centers for Medicare and Medicaid Services (CMS) onsite at Friendship Healtth Center December 8, 2020 with offsite record review completed on December 18, 2020.
The facility was not in substantial compliance with 42 CFR §483.80 Infection Control and Centers for Disease Control and Prevention (CDC) recommended practices to prevent and manage facility transmission of COVID-19.
Facility Census: 61 Resident Sample: 7
CMS surveyor: #29087
Federal Surveyors can be reached at:
US Department of Health and Human Services
Centers for Medicare and Medicaid Services
701 Fifth Avenue Suite 1600
Mailstop 400
Seattle, WA 98104
206.615.2313
A COVID-19 Focused Infection Control Revisit Survey was conducted by the Oregon State Survey Agency on 3/24/21.
The facility was found to be in compliance.
Total Residents: 61
Based on observation, interview, policy review, and record review the facility failed to implement and maintain an effective infection control program to contain and prevent facility transmission of COVID-19. The facility reported a current and active COVID-19 outbreak.
The facility failed to screen all visitors for COVID-19 symptoms or exposure to known COVID positive persons including travel out of area. The facility failed to ensure staff and contracted personnel used all recommended PPE in accordance with CDC guidelines, accepted standards of practice, and facility policy to prevent facility-transmission of COVID-19. The facility failed to ensure staff donned, and used N95 facemasks in accordance with CDC guidelines. Staff did not wash hands in accordance with CDC guidelines during 1 of 7 observations of handwashing. These failures increased the likelihood of facility-transmission and placed residents and staff at risk for exposure to and infection with COVID-19.
Findings include:
During an interview with Administrator, Director of Nursing (DNS) and Infection Preventionist (IP) on 12/8/20 at 8:00 AM. The administrator reported the facility experienced a current active outbreak of COVID-19 first identified in November 2020. The facility established a separate COVID unit located downstairs, isolated, and physically separated from the rest of the facility. The DNS reported the facility had completely dedicated COVID Unit staff who entered and exited the COVID Unit through a separate exterior door and did not access the rest of the building. The COVID Unit provided care only for confirmed COVID positive residents and was at capacity with 17 of 17 beds occupied. The facility census was 61. The facility was not accepting new admissions except for readmissions and/or residents from the campus community which included assisted living. The DNS and IP reported the facility did not have a designated space for quarantine or observation of new admissions or persons under investigation (PUI) for COVID which included persons with symptoms or known exposure to COVID-19. The facility maintained contact and droplet transmission-based precautions (TBP) for all residents house wide. IP stated it was a facility expectation that all staff wear an N95 or KN95 mask and face shield at all times while in the facility and in addition; staff must don a gown and gloves to enter a resident room.
The IP stated the facility followed Centers for Disease Prevention and Control (CDC) and Centers for Medicare and Medicaid (CMS) guidelines for prevention and management of COVID-19. The facility limited facility access to four entrances: B-wing for emergency personnel only, back of dining room for staff, street-side for COVID unit only and the main entrance. IP said essential visitors were screened for COVID-19 at the main entrance before entry to facility.
1. Surveyor (S1), an essential visitor, arrived at facility main entrance on 12/8/20 at 7:50 AM. The entrance was locked with signage that indicated no visitors due to COVID-19. S1 wore an N95 mask and face shield. A staff member (Staff 1) wearing uniform scrubs approached, opened the door and asked what S1 wanted. S1 showed credentials and stated the purpose was to conduct an infection control survey. Staff 1 did not identify herself. Staff 1 turned quickly and as she walked away told S1 to go upstairs to administration. Staff 1 did not conduct screening for COVID-19 and did not direct S1 to screening. S1 went up the stairs, walked through the corridor to the nurse station and was directed down the corridor to the administration offices.
Administrative staff (A1) sat at a desk in the administration office. S1 informed A1 of intent to conduct an infection control survey. When informed that surveyor was not screened for COVID-19 symptoms, COVID-19 exposure or travel and temperature was not checked at time of building entry, A1 said everyone had to be screened. A1 said the receptionist at the main entrance screened everyone who came into the building. When informed there was no receptionist present when surveyor arrived, A1 said the receptionist arrived at 8:45 AM and was the screener for visitors. A1 stated the facility kept the front door locked and an outside buzzer alerted the nurse station so the nurse could screen when the receptionist was not at her desk.
During an interview on 12/8/20 at 9:10 AM the receptionist (Staff 2) confirmed she was responsible for screening visitors before allowing entry into the building. When informed S1 arrived at 7:50 AM and was not screened, Staff 2 said the nurse should have gone to the lobby and screened S1. Staff 2 reported all staff were trained about screening procedures and requirements and all staff were screened before entering the building. Staff 2 said S1 had to be screened and requested S1 be screened. Staff 2 performed the screening procedures at that time including a questionnaire regarding symptoms, exposure to known or suspected COVID-19 positive persons, travel, and a temperature check. Staff 2 said employee screening stations were located in the dining room across the corridor. Staff 2 said she supervised employee screening during shift change from 1:45 PM to 2:45 PM.
On 12/8/20 at 10:00 AM when informed the facility staff did not conduct any screening of S1 prior to entrance into the facility. The facility Director of Nursing (DNS) said that was not acceptable, it was a facility requirement that all visitors be screened for COVID-19 prior to entering the facility.
2. On 12/8/20 at approximately 9:20 AM observation revealed activity Staff (3) self-screened in the dining room. Staff 3 entered through the back door to the dining room. New N95 masks were available at the sign-in station. Staff 3 obtained an N95 mask then filled out a questionnaire form, checked and recorded her temperature, then donned the N95 mask. Staff 3 obtained a face shield from a plastic bag that hung on a hook on the wall. Before leaving the dining room, Staff 3 washed her hands in the sink for a total of 7 seconds as timed by wristwatch. When asked about handwashing, specifically how long; Staff 3 said she should sing the Happy Birthday song in her head and acknowledged "I may have been short on the time to wash hands".
CDC handwashing guidelines per website CDC.gov accessed 12/10/20; excerpt below:
The CDC Guideline for Hand Hygiene in Healthcare Settings pdf icon[PDF - 1.3 MB] recommends:
When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers.
Rinse your hands with water and use disposable towels to dry. Use towel to turn off the faucet.
Avoid using hot water, to prevent drying of skin.
Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds.
Either time is acceptable. The focus should be on cleaning your hands at the right times.
3. On 12/8/20 at LN1 wore an N95 facemask that had two elasticized bands to hold the mask in place. The strap lowest on the mask was positioned high on LN1's head and the strap highest on the mask was positioned low behind LN1's neck. The straps crisscrossed on the back of her head. When asked about the N95 facemask, LN1 said she was trained how to don and doff the facemask. When asked about the crossed straps. LN1 said it was comfortable and stayed on better that way.
On 12/8/20 at 10:00 AM housekeeping staff (4) was observed and interviewed in the dining room. Staff 4 obtained a new model 8210 KN95 facemask. The facemask had two elasticized straps. Staff 4 cut the straps then tied the cut end of a top strap to a low strap on each side forming a loop with a rubber band in the loop. Staff 4 repeated the process on the other side resulting in one rubber band strap. Staff 4 said she had training about N95 masks and how to put them on and take them off. When asked why she used the rubber band, Staff 4 said she fixed her mask that way to keep it away from her ears. Staff 4 said without the rubber band, the mask caused pressure and hurt her ears.
A memo from IP dated October 14, 2020 and observed at the nurse stations, instructed staff to read the handout and watch a video at https://youtu.be/pGXiUyAoEd8. The video (viewed 12/9/20) directed users of disposable N95 masks to: inspect the mask including straps for tears or damage, do not criss-cross the straps, and follow all manufacturer's instruction for the specific model. The CDC website at CDC.gov accessed 12/9/20 included multiple articles and pictorials regarding the use of facemasks and N95 masks (respirators). The pictorial "Respirator On/Respirator Off" and the pictorial "Facemask Do's and Don'ts" directed *Do not use a respirator that is damaged or deformed and *Do not crisscross the straps. * Do not allow a strap to hang down and do not cross straps.
During an interview on 12/8/20 at 2:00 PM IP stated she was not aware staff were crisscrossing and modifying the straps on the face masks. IP staid the staff were trained how to don and doff facemasks properly and it was not acceptable to modify the facemask. IP said the staff should have informed her if the masks did not fit or were too uncomfortable to wear properly so the facility could obtain different styles/models of N95 facemasks.
F880COVID 19 screening 1.) Facility will ensure all Visitors complete COVID 19 screening upon entrance to facility, IP or designee will provide education to the proper staff with competencies, audit visitor screening forms against the visitor sign in log weekly x 4 weeks then monthly x 3 months. IP or designee will use results from audits and competencies to guide further education. 2.) All residents have the potential to be impacted by deficient practice. 3.) IP or Designee will report any deficient practice to QAPI for 3 months and then discontinue reporting to QAPI unless deficient practice continues 4.) Completed by 2/1/2021Hand Hygiene1.) IP or Designee will educate all staff on proper length of time to wash hands with soap and water. IP or designee will perform randomized hand hygiene competencies, and audits to ensure proper length of time washing with soap and water, weekly x 4 weeks then Monthly x 3 months. IP or designee will use results from audits and competencies to further guide education.2.) All residents have the potential to be impacted by deficient practices.3.) IP or designee will report any deficient practice to QAPI for 3 months and then discontinue reporting unless deficient practice continues 4.) Completed by 2/1/2021Wearing N95s correctly1.) IP or designee will educate all staff on the proper way to don an N95. IP or designee will perform randomized N95 strap placement audits and competencies, weekly x 4 weeks, then monthly x 3 months. IP or designee will use results from the audits and competencies to guide further education.2.) Will provide a platform to allow staff to communicate if the N95 mask is not fitting properly or prohibitive to their ability to function comfortably and provide alternative option.3.) All residents have the potential to be impacted by deficient practices4.) IP or designee will report any deficient practice to QAPI for 3 months then discontinue reporting unless deficient practice continues. 5.) Completed by 2/1/2021
Based on observation, interview, record review, and policy review the facility failed to ensure staff COVID-19 testing was conducted and documented in accordance with CDC guidelines and current standards of practice to prevent facility transmission of COVID-19.
Findings include:
In an interview on 12/8/20 at 10:30 AM, IP said the facility currently experienced an active COVID-19 outbreak. IP said the facility conducted contact tracing within the facility and found the outbreak most likely started with employees who worked on B wing. IP said 18 residents tested positive for COVID-19 "mostly on the B wing, but now a few positives were popping up on C-wing." IP said Resident (R1) was just added to the list of COVID positive residents this morning.
1. Observed signage posted throughout the facility read: Attention all staff. Mandatory COVID-19 testing. Next test dates: 12/8/20 12:00 PM to 2:00 PM. And 12/9/20 6:30 AM to 9:30 AM. During an interview on 12/8/20 at 10:30 AM, IP said she monitored the county positivity rate every Tuesday. IP said the Multnomah County COVID positivity rate posted for 12/8/20 was 10.6. IP said based on this positivity rate, the facility would continue twice a week testing of all employees who had no COVID positive test in the past 90 days.
IP said the facility utilized the services of a contracted onsite drug testing company (BF) to conduct COVID testing. IP said BF personnel conducted the sample collection (nasal swabbing) in the facility, processed the tests, and loaded the test results on a website within a couple of days.
The facility census report indicated R3 was on the COVID Unit. A brief review of R3's health record found no COVID test result to support admission to the COVID Unit. The most recent laboratory report of COVID-19 testing dated 10/22/20 showed the test was negative for COVID-19.
A progress note dated 11/16/20 at 11:08 PM indicated R3 provided verbal consent for COVID-19 testing. The progress notes did not state why consent was obtained and did not indicate if a COVID test was performed.
A progress note dated 11/18/20 at 12:14 AM noted the reason for alert charting was "COVID exposure." The EHR did not describe the circumstances or how and when the exposure occurred for R3.
A progress note dated 11/19/20 at 6:14 PM written by the Resident Care manager (RCM1) indicated the "MD, resident, and wife were notified of positive COVID results" and the plan to move R3 to the COVID wing. The EHR did not include laboratory documentation or a report of a COVID positive test for R3.
IP was interviewed on 12/8/20 at 2:20 PM. When informed laboratory documentation for COVID tests to include the date of collection, the specific test performed, the test result, and the date the test results were reported to facility could not be located in Resident R3's health record for negative COVID tests conducted 8/26/20 and 11/23/20, and no laboratory report for positive COVID tests on 11/16/20, and 11/20/20. Test results could not be located in R5's health record for negative COVID tests conducted on 7/21/20 and 11/16/20, or for a positive COVID test on 11/22/20. IP confirmed the findings and stated other residents would have similar findings of lack of documentation from the laboratory regarding COVID test results.
IP said she had been "trying to get individualized COVID results for the past five weeks with no luck." IP stated obtaining a written report for each resident's COVID test was an ongoing problem. IP said all she could get was an excel spreadsheet with everyone's COVID test results in one report. IP said the facility tried to figure out how to separate each resident's information to scan into the EHR (electronic health record) but the file was so big it kept crashing the facility computers. IP acknowledged the lack of laboratory COVID-19 test reports in the health records depending on which laboratory was used. IP said a narrative progress note in the EHR was the only place the facility documented that a COVID test was done and the results of that test.
Additional review of R3's health record conducted offsite on 12/18/20 through remote electronic access revealed a nurse note dated 11/20/20 at 4:55 PM that read: "This nurse [LN2] performed a COVID-19 at 3:55 PM" and the note indicated nursing staff called R3's wife to inform her of the test being done and to expect results sometime over the weekend. The progress notes did not indicate whether the nurse actually performed a COVID test or collected a specimen to send out to the lab. The EHR did not contain documentation from the laboratory to show this test was performed with a positive result.
The date stamps in the EHR indicated laboratory reports documenting COVID testing with negative results on 8/26/20 and 11/23/20 and positive COVID results on 11/16/20 and 11/20/10 were uploaded (added to) the R3's EHR on 12/8/20 after surveyor requested documentation for the COVID tests on 12/8/20.
Similar findings were noted for R5. Laboratory reports documenting COVID testing with negative results on 7/21/20 and 11/16/20 and COVID positive test result on 11/22/20 were uploaded to R5's EHR on 12/8/20 and 12/9/20 after surveyor requested documentation off the COVID test results on 12/8/20.
2. During an interview on 12/8/20 at 10:30 AM, IP said staff COVID test specimen collection (nasal swabbing) was conducted in the facility twice a week. IP said the facility did not have written procedures for sample collection for COVID testing because BF personnel conducted the testing for staff. IP said she did not know if BF had policies and procedures consistent with CDC and/or CMS guidelines. IP stated specimen collection (swabbing) was conducted in the first floor dining room.
Observation (conducted while maintaining social distancing of more than six feet) in the dining room from 12:30 PM to 1:15 PM revealed a supply of KN95 masks near the entrance/exit at the back of the dining room. An employee screening station was set up at table nearby with a binder, questionnaires, pens, and thermometers. One wall was covered with plastic bags that hung on hooks, some of the bags held face shields or goggles intended for reuse. Two eye protection sanitizing stations with instructions and supplies were set up on a sink counter near the door leading to the main corridor.
Three persons identified as BF contracted personnel (BF1, BF2, and BF3) wore blue plastic gowns, two face masks (layered), and gloves. BF1 sat at a table (1) near the dining room entrance (from the corridor). BF1 had a paper spreadsheet, a supply of swabs and plastic specimen bags. BF3 sat at the table with BF1 and noted names as randomly observed (RO) staff approached table 1. BF1 requested each staff person to label the specimen container (capped test tube) and then directed the staff to table 2 or 3 with the specimen bag, swab stick, and container in hand.
BF2 stood near table 2. BF2 wore a blue plastic gown that was tight and the sleeves stopped above the wrists. BF2 wore clear vinyl gloves that were loose at the top (cuff edge) exposing several inches of bare skin on both arms. C2 stood on one side of the table and RO1 stood on the other side. The table was one arm's length wide. C2 took the supplies from RO1 and instructed RO1 to remove or drop his mask down to swab the inside of his right nostril while rotating the swab stick around to the count of 10. This process was repeated with the same swab stick in the left nostril. RO1 held the swab stick and performed the swab as directed. When RO1 finished swabbing, C2 held out the specimen container for RO 1 to insert the tip of the swab stick. C2 then held the swab stick in his hand and broke off the end so the container could be sealed with the cap. C2 held the end of the swab stick that RO1 held in his hand and up to his face and nose while unmasked which contaminated the swab stick. C2's gloves were contaminated by the swab stick, C2 placed the specimen container in the plastic specimen bag with the contaminated gloves and handed the specimen bag back to RO1 who returned the specimen bag to C1. C1 held the specimen bag in her gloved hand then placed it in a basket that held many other specimen bags. C2 did not remove his gloves, C2 used a spray bottle of disinfectant to wipe down the table then used ABHR (alcohol-based hand rub) to sanitize his gloved hands.
While wearing the same gloves, C2 repeated the process with four more randomly observed staff. IP was called to the dining room to observe with surveyor. IP observed C2 collect nasal swab specimens from two additional randomly observed staff. C2 was directly observed to wear the same gloves for six consecutive swab collections.
Multiple activities occurred in the dining room while COVID testing continued. Several randomly observed staff entered through the dining room and self-screened, then removed eye protection from bags hung on the wall, donned the eye protection, performed hand hygiene at a hygiene station, and then exited the dining room. Although the testing stations were at least six feet apart social distancing was not maintained when staff utilized the eye protection sanitization station and when more than one staff were at the screening station. Staff came and went from the facility through the employee entrance/exit in the dining room.
When asked about the observations IP said she was not aware BF personnel did not change gloves between specimen collections. IP stated the part that concerned her most was that BF2 handled and broke off the swab stick which the employee had contaminated and then also handled the plastic specimen bag with contaminated gloves. IP said she did not supervise or oversee the contracted company BF. IP said BF was approved by the state for COVID testing and IP said they followed Oregon rules OAR 411-060-0050 so she trusted they knew how to conduct testing. IP said BF personnel worked independently. When asked about CDC infection control guidelines, IP said since the company, BF, was approved by the State of Oregon she assumed they followed all rules and guidelines.. IP said she did not know if it was acceptable to sanitize gloved hands while conducting COVID testing and would have to research it.
Review of the facility policy and procedure titled "Coronavirus (COVID-19) Testing" with a review date of 10/20 read in part; [The facility] will consider the CDC recommendations, CMS guidelines, Oregon Health Authority recommendations and Oregon Administrative Rules for testing staff and residents for COVID-19. This policy may frequently need updating due to the frequent changes in recommendations/rules regarding COVID-19 testing in Long Term Care Facilities that must be followed.. The policy and procedure addressed surveillance testing, outbreak testing, and symptomatic testing and the required frequency of testing. The policy and procedure did not indicate the testing location within the facility, and did not provide direction regarding use of PPE by contracted personnel when collecting nasal swabs, environmental controls during testing such as limiting number of persons, other activities, and travel through the testing area. The policy did not address sanitization of surfaces during testing and terminal room sanitization at the end of the testing day.
In a follow-up telephone interview on 12/17/20 at 11:40 AM IP reported she "went on the hunt" to find information to support BF personnel practice of using ABHR (alcohol-based hand rub) on gloved hands rather than changing gloves after each COVID test sample collected. IP said she could not find any reference sources regarding use of ABHR to sanitize gloved hands when swabbing for COVID testing. IP said she spoke with BF representatives and they did not have references to support their practice to sanitize gloves with ABHR for extended use when conducting swabbing for COVID testing. IP said they were probably doing it to save on the number of gloves used. When asked if the facility or BF experienced a current shortage of gloves, IP said no. IP said BF denied a shortage of gloves and IP said she informed BF that the facility could supply gloves if needed.
The CDC website accessed on 12/9/20 at https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care.html Performing Facility-Wide SARS-CoV-2 Testing in Nursing Homes; Location of specimen collection for HCP (health care personnel)
*The number of people present during specimen collection should be limited to only those essential for care and procedure support. Ideally, specimen collection should be performed one individual at a time in a room with the door closed and no other individuals present, if individual rooms are not available, other options include: -large spaces (e.g., gymnasiums) where sufficient space can be maintained between swabbing stations (e.g., greater than 6 feet apart).
Considerations for multiple HCP being swabbed in succession in a single room: Minimize the amount of time the HCP will spend in the room. HCP awaiting swabbing should not wait in the room where swabbing is being done. Those swabbed should have a face mask or cloth cover in place for source control throughout the process, only removing it during swabbing.
Minimize the equipment kept in the specimen collection area.
Consider having each person bring their own prefilled specimen bag containing a swab and labeled sterile viral transport media container into the testing area from the check-in area.
PPE for swabbing: *HCP in the room or specimen collection area should wear an N95 or higher-level respirator (or facemask) and eye protection. A single pair of gloves and a gown should also be worn for specimen collection or if contact with contaminated surfaces is anticipated. *extended use of respirators (or facemasks) is permitted *Gloves should be changed and hand hygiene performed between each person being swabbed. *Gowns should be changed when there is more than minimal contact with the person or their environment. The same gown may be worn for swabbing more than one person provided the HCP collecting the test minimizes contact with the person being swabbed. Gowns should be changed if they become soiled.
The facility policy and procedure titled "Management of a COVID-19 Pandemic" with a review date of 11/30/20, page 5 read: 5. Mass COVID-29 testing: 5a. If a COVID positive staff or patient/resident has been identified, facility will perform outbreak testing per public health, CMS and licensing authority guidance. 5b. listed seven companies that may have capability of assisting facility to test and process COVID-19 labs for staff and patients/residents. The list included Butterfield (BF) an onsite drug testing company. 6. Infection control procedures will be followed per other COVID-19 and droplet precaution facility policies.
F886COVID test entered correctly in the resident records 1. Resident # record has been updated to include the COVID-19 test results. 2. 100% audit will be completed by DNS or designee to ensure that COVID-19 results are current in the medical records. 3. IP or designee will educate appropriate staff on proper procedures for COVID 19 testing documentation in the resident record. Medical Records or designee will perform randomized COVID-19 resident testing documentation audits weekly x 4 weeks, then monthly x 3 months. IP or designee will use results from the audits and competencies to guide further education.4. All residents have the potential to be impacted by this deficient practice 5. IP or designee will report any deficient practice to QAPI for 3 months then discontinue reporting unless deficient practice continues. 6. Completed by 2/1/2021Mass testing of staff for COVID 191. Administrator or designee to review and update COVID-19 Testing Policy and Procedure to follow local and federal guidelines in relation to PPE used by personnel present during COVID-19 swab collection, environmental controls, social distancing and sanitation during mass COVID-19 testing. Administrator or designee to perform randomized COVID-19 testing audits weekly x 4 weeks, then monthly x 3 months. IP or designee will use results from the audits and competencies to guide further education.2. All residents have the potential to be impacted by this deficient practice. 3. IP or designee will report any deficient practice to QAPI for 3 months then discontinue reporting unless deficient practice continues. 4. Completed by 2/1/2010
