A COVID-19 Focused Emergency Preparedness Survey was conducted by the Oregon State Survey Agency on 12/3/20 to 12/4/20. The facility was found to be in compliance with 42 CFR 483.73 related to E-0024 (b) (6).
Total Residents: 105
A COVID-19 Focused Infection Control Survey was conducted by the Oregon State Survey Agency on 12/3/20 to 12/4/20.
Deficiencies were cited.
Total residents: 105
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 2/4/21.
The facility was found to be in compliance with 42 CFR Sec. 483.80.
Total Residents: 101
Based on observation, interview and record review it was determined the facility failed to provide quality of care when emergency equipment and emergency supplies were not readily accessible for 5 of 5 residents (#s 2, 3, 7, 8, and 9) who were positive for COVID-19 and who resided in a unit separate from the facility. This failure, determined to be an immediate jeopardy situation, placed residents with COVID-19 at risk for delayed emergency interventions, serious harm and/or death in the event of rapid physical deterioration related to the COVID-19 disease progression. Findings include:
The Centers for Disease Control and Prevention (CDC) Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19) outlined clinicians should be aware of the potential for some patients with COVID-19 to rapidly deteriorate about one week after illness onset. Age is a strong risk factor for severe illness, complications and death. Older adults are more likely to get severely ill from COVID-19. More than 80% of COVID-19 deaths occur in people over age 65, and more than 95% of COVID-19 deaths occur in people older than 45. Adults of any age with the following conditions can be more likely to get severely ill from COVID-19: Dementia, Diabetes type 2, heart failure and stroke.
The CDC Basics of Oxygen Monitoring and Oxygen Therapy during the COVID-19 Pandemic outlined many people with COVID-19 have low oxygen levels, a life-threatening condition. If the patient has any warning signs of low oxygen levels, start oxygen therapy immediately.
The 2020 COVID-19 Federal Healthcare Resilience Task Force Alternate Care Site (ACS) Toolkit Third Edition outlined to be considered fully functional, an ACS must include:
- Not only the facility (the space), but also the appropriate personnel (the staff) and medical equipment and supplies (the stuff) for health care delivery (the service);
- Alternate backup oxygen sources (e.g., reserve oxygen cylinders, oxygen concentrators, liquid oxygen [LOX] tanks);
- Unintended consequences of an insufficient supply chain should be taken in consideration. Alternate oxygen reserve (e.g., bottled, tanks) are critical for oxygen needs to ensure that oxygen supply and delivery does not get interrupted.
On 12/3/20 at 3:45 PM a tour of the COVID-19 unit was conducted by two surveyors. The unit was a portable building located on the outer east edge of the facility's parking lot and was separate from the facility. Upon entrance to the COVID-19 unit, a closed door to the right led to the room where the residents resided. Upon entrance to the room, Resident 2, Resident 3, Resident 7, Resident 8 and Resident 9 were observed by two surveyors. Resident 7 was observed with supplemental oxygen supplied via nasal cannula tubing from an oxygen concentrator. Resident 8 was sitting up in a wheelchair watching TV. Resident 2, 3 and 9 were lying in bed. Continued observations of the COVID-19 unit revealed no emergency equipment and no emergency supplies in the unit such as a suction machine (an appliance used to remove mucus and saliva from a person's airway), suction collection canisters, suction connecting tubing, suction catheters, saline solution, full oxygen tanks, oxygen concentrators, oxygen tubing and oxygen cannulas. Observations of a small closet like storage area in the room revealed three empty oxygen tanks and other resident care equipment such as a mechanical lift and linens. When interviewed by two surveyors, Staff 4 (RN) stated she was the nurse on duty for the COVID-19 unit and confirmed no emergency equipment and no emergency supplies were stored and accessible on the unit. Staff 4 stated the portable COVID-19 unit was used prior as a classroom and the empty oxygen tanks were props, did not contain oxygen and were nonfunctional. Staff 4 stated all emergency equipment and emergency supplies were kept inside the facility and if these items were needed, the protocol was to call staff inside the facility and staff would deliver the items to the portable COVID-19 unit. When asked about obtaining supplemental oxygen for Resident 7, Staff 4 stated on 12/2/20 Resident 7's oxygen saturations became low and supplemental oxygen was needed. Staff 4 stated she did not have oxygen tanks, an oxygen concentrator or oxygen tubing on the COVID-19 unit and the oxygen concentrator and oxygen tubing was delivered from the main facility.
Resident 2 was admitted to the facility with diagnoses including Diabetes Mellitus type 2 and was 88 years old. Resident 2's age and diagnosis placed the resident at high risk for complications of COVID-19.
Resident 3 was admitted to the facility with diagnoses including cerebral infarction (stroke) and was 89 years old. Resident 3's age and diagnosis placed the resident at high risk for complications of COVID-19.
Resident 7 was admitted to the facility with diagnoses including congestive heart failure and Parkinson's Disease and was 83 years old. Resident 7's age and diagnosis placed the resident at high risk for complications of COVID-19.
Record review revealed on 12/2/20 Resident 7's oxygen saturations decreased to 84% and the resident required supplemental oxygen to maintain oxygen levels above 90%.
Resident 8 was admitted to the facility with diagnoses including Diabetes Mellitus type 2 and was 71 years old. Resident 8's age and diagnosis placed the resident at high risk for complications of COVID-19.
Resident 9 was admitted to the facility and was 85 years old. Resident 9's age placed the resident at high risk for complications of COVID-19.
On 12/3/20 at 5:35 PM two surveyors assessed the route from the COVID-19 unit to the entrance of the facility's Alpha Wing. Surveyors briskly walked the route between the portable COVID-19 unit and the closest facility entrance. From the exit of the COVID-19 unit, brisk walking was two minutes one way to reach the doors of the Alpha Wing. The route was an irregular and uneven walkway, partially graveled with no pathway lighting, was dark and difficult for surveyors to navigate. Once inside the facility doors, the emergency equipment and emergency supplies, including oxygen, were located on a cart an additional 50 feet from the Alpha Wing entrance door down the hallway.
On 12/3/20 at 5:45 PM Staff 14 (Agency RN) stated she was the nurse on the Alpha Wing. Staff 14 stated she did not know the location of the emergency equipment and emergency supplies, including oxygen and was unsure of the procedure for delivering those items to the COVID-19 unit.
On 12/3/20 at 7:03 PM Staff 1 (Administrator) and Staff 2 (DNS) were informed of the immediate jeopardy (IJ) situation related to the facility's failure to provide quality of care when emergency equipment and emergency supplies were not readily accessible on the COVID-19 unit in the event of residents' rapid physical deterioration. The IJ template was provided and an immediate IJ removal plan was requested.
On 12/3/20 at 8:26 PM the facility submitted a removal plan which was accepted and approved by the survey team.
The IJ Removal Plan indicated the facility would implement the following actions:
- The COVID-19 unit RN was notified to immediately call the Alpha Wing nurse if emergency equipment and emergency supplies were needed.
- The Alpha Wing RN was educated on the procedure and the location of the emergency equipment and emergency supplies cart.
- An inventory of necessary emergency equipment and emergency supplies would be completed.
- Full oxygen tanks would be supplied on the COVID-19 unit.
- An emergency equipment and emergency supplies cart with the necessary items such as suction machine, suction collection canisters, suction connecting tubing, suction catheters, saline solution, oxygen tubing and oxygen cannulas would be placed on the COVID-19 unit.
On 12/4/20 at 10:31 AM surveyors verified all elements of the IJ removal plan were completed and emergency equipment and emergency supplies were readily accessible on the COVID-19 unit.
F684 DPS: Based on observation, interview and record review it was determined the facility failed to have emergency equipment and supplies readily accessible for 5/5 residents who were positive for COVID-19 and who resided in a unit separate from the facility. This failure determined to be an IJ situation, placed residents with COVID-19 at risk for delayed emergency interventions, serious harm and/or death in the event of rapid physical deterioration related to the COVID-19 disease process. This alleged deficient practices were corrected in the following way. 1.) Corrective action for the residents affected by the alleged deficient practice: - COVID unit RN was educated by DNS on 12/3 to contact Alpha wing RN if emergency equipment needed - DNS educated Alpha wing nurse on code cart location 12/3 - LN in facility gathered emergency supplies and stocked isolation unit 12/3- RCA completed 12/22 by IDT- Residents that were affected are currently stable and monitored every shift for emergent needs.2.) Corrective action taken for those residents having the potential to be affected by the alleged deficient practice: - DNS educated in house agency LNs on code cart location and procedure 12/28.- ADON audited all facility code carts to ensure proper supplies are available 12/28. - The facility does not currently have any residents who are COVID positive.3.) Measures/systematic changes put in place to assure the alleged deficient practice does not reoccur:- Added code cart education to agency onboarding process 12/4. - Code cart education for all staff annually and upon hire via Relias.- Code cart supply checklist was created by ADON 12/30.- Updated safety committee Facility Environmental Observation checklist to include staffs knowledge of code cart location.- Education regarding this survey and its POC will be presented by ADON, DNS and IPCO via Zoom prior to 1/23/21 for LNs. Meeting will be recorded and distributed to all LN staff via email.4.) Corrective actions will be monitored to ensure the alleged deficient practice will not reoccur: - Will audit staff knowledge of code cart location via safety committee Facility Environmental Observation quarterly by safety committee and other random times by DNS or designee.- Audit all code carts for necessary supplies Q weekly by NOC LN.- ADON to monitor audit completion monthly. - All audit findings reported to QAPI x 6 months. 5.) DNS and Administrator are responsible for this POC.6.) Completion date: 1/23/2021
Based on observation, interview and record review it was determined facility failed to follow appropriate infection control practices in a manner to reduce and/or prevent the potential contamination and spread of the COVID-19 virus in 5 of 5 units and 1 of 1 kitchen reviewed. This placed residents at risk for cross contamination and possible exposure to infectious agents. Findings include:
1. The CDC (Centers for Disease Control and Prevention), "Coronavirus 2019 (COVID-19)", last revised 6/19/20, instructed healthcare workers to perform hand hygiene before and after all patient contact, before and after removing PPE (Personal Protective Equipment), including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process.
Review of the undated facility Hand Hygiene Policy/Procedure, provided 12/4/20, revealed "when careful hand hygiene must be performed: before and after resident contact; before aseptic technique; after body fluid exposure; after contact with resident surroundings, clothing, linens and equipment; when moving from a dirty resident task to a clean task; before and after gloves are used; before passing food trays; after personal use of toilet; after smoking; and after eating."
On 12/3/20 between 9:00 AM to 7:45 PM, multiple observations were made of staff not performing hand hygiene. Examples include the following:
- at 9:58 AM, Staff 10 (CNA) was observed to touch her face mask and her goggles multiple times, then touch the hallway handrail with no hand hygiene. Staff 10 acknowledged staff should perform hand hygiene if they touch their face mask or goggles (eye protection);
- at 10:13 AM, Staff 12 (Activities) was observed to touch a resident on the back, push resident down the hallway, open the door to the outside smoking area and push resident in her/his wheelchair outside. Staff 12 then picked up a smoking apron from a chair and placed it on resident. Staff 12 reached in his pocket, pulled out a pack of cigarettes, opened the pack and pulled out a cigarette and lit the cigarette for the resident. Staff 12 had no hand hygiene through the observation;
- at 10:18 AM, Staff 13 (Housekeeping) was observed to leave resident room C147 with gloves. Staff 13 proceeded to place a mop in the mop bucket with his gloved hands, push the mop down the hallway and emptied the water from the mop bucket. At 10:22 AM, with the same pair of gloves donned, Staff 13 took a plastic bag down the center hallway, touched the doors to exit the unit, and was observed to enter the doors on the right which lead to the housekeeping office, laundry and kitchen with no hand hygiene;
- at 11:35 AM, Staff 16 (housekeeping/laundry) was observed to deliver clean personal resident clothing from a covered cart with gloves donned. Staff 16 exited room D146, with the same gloves and no hand hygiene. Staff 16 entered room D148 and collected hangers, placed clothes in resident closet, exited the room with same gloves and no hand hygiene. Staff 16 proceeded down the hallway entering rooms with the same gloves and no hand hygiene between rooms. Surveyor provided technical assist to change gloves and perform hand hygiene between resident rooms. Staff 16 stated "ok" and continued enter and exit three more resident rooms with no hand hygiene and with same gloves;
- at 10:51 AM, Staff 12 was observed to push Resident 12 out to smoking area. Staff 12 touched the wheelchair handles, handrails and the door to go outside. Staff 12 picked up a smoking apron, placed on resident's lap, took cigarette pack out of his pocket, touched a filter side of the cigarette, gave to the resident and lit the cigarette for the resident. No hand hygiene was performed;
- at 11:01 AM, Staff 21 (Charge Nurse) was observed to touch her face mace mask then touch papers with no hand hygiene;
- at 11:40 AM, Staff 12 assisted a residents in the dining area with unwrapping individual candies, looked at a cell phone from his pocket, touched several residents' wheelchairs and shoulders with no hand hygiene performed between;
- at 11:40 AM, Staff 9 (CNA) sat at the nursing station and touched her face mask. Staff 9 touched the nursing station desktop and no hand hygiene performed.
In an interview on 12/3/20 at 10:27 AM, Staff 13 stated he should have changed gloves after leaving a resident room and not wear dirty gloves in the hallways or to leave a unit.
During an interview on 12/3/20 at 12:30 PM, Staff 12 confirmed he had not performed hand hygiene between touching the items and residents in the dining area.
On 12/4/20 at 10:31 AM, Staff 17 (CNA) was observed on the COVID-19 positive unit to take off her N95 face mask and face shield with no hand hygiene, and stuff the N95 into a plastic bag with her face shield, crumbled together and folded. Staff 17 stated she thought it was ok to store them together.
On 12/4/20 at 12:23 PM, Staff 4 (Infection Control Preventionist) reported staff were expected to perform hand hygiene after touching a potentially contaminated surface, including face masks. Staff 4 stated the N95 face masks and face shields should not be stored in the same plastic bag.
On 12/4/20 at 2:29 PM, Staff 1 (Administrator) acknowledged staff were expected to perform hand hygiene.
2. Centers for Disease Control (CDC), updated 6/19/20, refers to the facility to implement Universal Source Control which refers to facemask's to cover a person's mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing or coughing. Because of the potential for asymptomatic and pre-symptomatic transmission, source control measures are recommended for everyone in a healthcare facility, even if they do not have symptoms of COVID-19. Staff should wear a facemask at all times while they are in the healthcare facility, including spaces where they might encounter co-workers. Staff should be aware about the importance of performing hand hygiene immediately before and after any contact with their facemask or cloth face covering. Do not wear respirator/facemask under [the] chin or store in scrubs pocket between patients.
Oregon Health Authority, Public Health Office of Disease Prevention and Epidemiology, dated 7/20/20, instructed "staff should wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected. Face shields or goggles are appropriate, but face shields are preferred as they may provide additional protection for the nose and mouth. Masks and eye protection should be worn at all times while in the facility, including in breakrooms or other spaces where they might encounter co-workers. When masks and eye protection need to be removed (e.g., to eat meals or upon leaving the facility), strict social distancing should be observed."
On 12/3/20 at 12:06 PM and 12:23 PM, Staff 12 (Activities), was observed outside in the smoking area to take off his goggles (eye protection) while he stood within three feet of a resident not wearing a mask.
In an interview on 12/4/20 at 12:30 PM, Staff 12, confirmed he did not wear eye protection while standing within six feet of a resident.
On 12/3/20 at 3:00 PM, dietary staff were observed in the kitchen to sit closer than six feet of each other. One staff observed with no face mask or eye protection.
On 12/3/20 at 6:48 PM, three staff including Staff 20 (CNA) were observed to sit at the nursing station, within six feet of each other, with eye protection pushed up and rested on top of their head, not their covering eyes.
On 12/3/20 at 6:58 PM, Staff 20 was observed with eye protection on top of her head. Staff 18 (Charge Nurse), acknowledged staff were expected to wear eye protection correctly and social distance and he would direct staff to social distance and wear required PPE.
On 12/4/20 at 12:23 PM, Staff 4 (Infection Control Preventionist) acknowledged the staff were expected to wear eye protection while in the facility.
On 12/4/20 at 2:29 PM, Staff 1 (Administrator) was notified of staff not wearing eye protection and she acknowledged the expectation was for staff to wear eye protection at the facility.
3. Centers for Disease Control (CDC) Preparing for COVID-19 in Nursing Homes, dated 6/25/20, 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, updated 11/12/20, showed "A mask is NOT a substitute for social distancing. Masks should still be worn in addition to staying at least 6 feet apart."
On 12/3/20 at 9:37 AM, no residents on the Delta unit were observed with face masks donned.
On 12/3/20 at 10:08 AM, Staff 10 (CNA) reported residents do not have to wear face masks while on the unit but if a resident left the unit, she would offer a face mask. Staff 10 stated the Kardex (care plan) would direct her if a resident needed a face mask. Staff 10 acknowledged she did not offer residents face masks daily.
On 12/3/20 at 10:11 AM, six residents were observed on the Charlie Wing dining area with no face masks and were not socially distanced.
On 12/3/20 at 11:37 AM, Resident 13 stated the facility did not offer residents face masks to wear on the Charlie unit.
On 12/3/20 at 11:40 AM, two residents were observed at a dining room table, sat within six feet of each other and did not have a face mask donned.
On 12/3/20 at 11:44 AM, Staff 9 (CNA) reported all residents should wear a face mask when out of their rooms. Staff 9 proceeded to offer the seven residents in the dining area masks with very quick question of "do you want a mask or not?" no additional encouragement was observed to residents to wear masks.
On 12/3/20 at 12:01 PM, Resident 11 reported the Charlie unit staff would offer a resident a face mask if they left the unit. Resident 11 stated she/he had not been offered a face mask to wear on the unit.
On 12/3/20 at 12:07 PM, no residents on the Alpha unit were observed to wear a face mask. Two of the residents were sitting at the same table, less than six feet apart. Staff 6 (RN) acknowledged the residents were not wearing a face mask and moved the residents apart to social distance.
Record review on 12/3/20 at 3:26 PM, revealed for Resident 1, Resident 2, Resident 3, Resident 4 nor Resident 5 had no documentation for face mask use.
On 12/3/20 at 12:19 PM, all residents observed out of their rooms on the Alpha unit were not wearing face masks.
On 12/4/20 at 10:33 AM, one resident was observed in the Bravo dining room and one resident in the hallway with no facemask donned. No other residents were out of their room.
On 12/4/20 at 11:15 AM, Staff 8 (CNA) acknowledged some staff do not have time to offer face masks daily.
On 12/4/20 at 12:23 PM, Staff 4 (Infection Control Preventionist) acknowledged the staff were expected to offer residents face masks daily.
On 12/4/20 at 2:29 PM, Staff 1 (Administrator) acknowledged residents were expected to be offered face masks on the units.
4. Centers for Disease Control "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic" revised 7/15/20 instructed facilities to ensure environmental cleaning and disinfection procedures were followed consistently and correctly.
Oregon Health Authority updated "Frequently Asked Questions: Universal Eye Protection in Long-Term Care Facilities" directed facilities to establish a dedicated area to clean and disinfect reused eye protection.
On 12/3/20 at 10:50 AM, Staff 5 (CNA) doffed her face shield and stated she was unaware of any contact time (dwell time) for the disinfectant. Staff 5 stated she had not been trained about disinfectant contact time.
On 12/3/20 at 11:44 AM, Staff 22 (Activity Assistant) and Staff 23 (LPN) stated they were unsure of the contact time for the disinfectant used on the unit.
On 12/3/20 at 3:00 PM, Staff 24 (Assistant Dietary Manager) stated she was unsure of the contact time for the disinfectant when she donned/doffed her PPE at end of shift.
On 12/4/20 at 9:00 AM, Staff 15 (Activities/Screener) greeted surveyors at the front entrance of the facility. Staff 15 took the three surveyors' temperatures with the same thermometer. Staff 15 did not disinfect the thermometer between each surveyor and set the thermometer directly on the table. Staff 15 reported she disinfected the thermometer usually about every four to five people. Staff 15 had a spray bottle of disinfect and a rag to the rear of her chair on the floor. Staff 15 was not aware of any specific wait time (dwell time) for the disinfectant.
On 12/4/20 at 12:23 PM, Staff 4 (Infection Control Preventionist) acknowledged the staff were expected to know the contact time (dwell time) for disinfectants and should adhere to the times.
On 12/4/20 at 2:29 PM, Staff 1 (Administrator) acknowledged staff were expected to follow the products contact times for disinfectants.
5. On 12/3/20 at 10:50 AM, Staff 5 (CNA) stated she was not trained on disinfecting PPE.
On 12/3/20 at 6:48 PM, three staff including Staff 20 (CNA) and Staff 18 (Charge Nurse) were observed to sit at the nursing station, within six feet of each other, with eye protection pushed up and rested on top of their heads, not covering eyes.
In an interview on 12/4/20 at 12:23 PM, Staff 4 (Infection Control Preventionist) reported the staff were trained on the computer training program modules on an individual basis, CDC posters and in real-time education had been provided when she or RCM's observed a concern. Staff 4 reported there was no system for evaluation of staff skills and competencies related to infection control.
During an interview on 12/4/20 at 2:13 PM, Staff 2 (Assistant Administrator) and Staff 3 (DNS) reported the RCM's were assigned to audit and ensure completion of the CNA trainings. The audits were random with no schedule. Staff 3 stated since COVID-19 these was no on-going infection control training and the program was not as organized as in the past and no documentation confining audits had been completed.
Record review of the past audits and competencies provided on 12/4/20 at 2:20 PM, revealed the following:
-2019, four blood glucose audits;
-8/2020 and 11/2020, four CNA competencies were provided;
-11/10/20 of hand hygiene and eye protection,revealed 11 audits for three of the 11 were complete;
- No other Audits or competencies were provided.
On 12/4/20 at 2:29 PM, Staff 1 (Administrator) acknowledged the lack of audits and documented training for infection control.
No additional information was provided.
F880 DPS: Based on observation, interview and record review it was determined the facility failed to follow appropriate infection control practices in a manner to reduce and/or prevent the potential contamination and spread of the COVID-19 virus in 5/5 units and 1/1 kitchen reviewed. This placed residents at risk for cross contamination and possible exposure to infections agents. A.) Hand Hygiene1.) Corrective action for the residents affected by the alleged deficient practice: - There is no evidence of resident infection at this time due to the alleged deficient practice.2.) Corrective action taken for those residents having the potential to be affected by the alleged deficient practice: - All residents and staff could be at risk due to alleged deficient practice. 3.) Measures/systematic changes put in place to assure the alleged deficient practice does not reoccur: - IPCO will update Hand Hygiene Policy and Procedure to include COVID-19 standards using CDC as guide.- All staff will be educated of updated Hand Hygiene Policy and Procedure, performed by Department Heads, Nurse Managers/Directors and via Relias Training.- Education regarding this survey and its POC will be presented by ADON, DNS and IPCO via Zoom prior to 1/23/21 for LNs. Meeting will be recorded and distributed to all LN staff via email.- Random Hand Hygiene Audits to be performed by Department Heads and RCM’s, (or DNS’s designee) weekly x’s 4 weeks, results reported to ADON - Return Demonstration Hand Hygiene Competency performed annually at time of performance evaluation by RCM.- Hand Hygiene observations added to safety committee “Facility Environmental Observation” checklist to be performed quarterly by Safety Committee Designee and results reported to QIC.- Individual Hand Sanitizers ordered for all staff. - Additional Hand Sanitizing stations added to resident smoking areas.- Additional Hand Sanitization stations added throughout building.4.) Corrective actions will be monitored to ensure the alleged deficient practice will not reoccur: - ADON will review Hand Hygiene Audits and report findings to QAPI for review and follow up for PDSA cycle of learning. Audit findings reported for 4 weeks. - Individual education will be provided with staff if deficient practice is noted during audits.- If deficient practices continue to be noted after 4 weeks, will continue audits for additional timeframe to be determined and report to QAPI.- HR to report Hand Hygiene Return Demonstration Competency Findings monthly to QIC for review and follow up at QAPI for 6 months.- QIC to review Safety Committee Observations for Hand Hygiene and report findings to QAPI for follow up for 6 months.5.) DNS and Administrator are responsible for this POC.6.) Completion date: 1/23/21B. Staff eye protection use/social distancing: 1) Corrective action for the residents affected by the alleged deficient practice: - There is no evidence of residents being affected at this time due to the alleged deficient practice.2) Corrective action taken for those residents having the potential to be affected by the alleged deficient practice: - All residents and staff could be at risk due to alleged deficient practice.3) Measures/systematic changes put in place to assure the alleged deficient practice does not reoccur:- PPE DON/DOFF audit created by IPCO- Random PPE DON/DOFF audit to be completed by department head or nurse management designee, weekly x’s 4 weeks, results reported to IPCO- Return Demonstration of PPE DON/DOFF Competency performed annually at time of performance evaluation by RCM.- Proper wearing of Eye Protection Audit added to safety committee “Facility Environmental Observation” checklist, to be performed quarterly by Safety Committee Designee and results reported to QIC- Proper Social Distancing for all staff audit to be performed weekly by Department Head or nurse management designee, weekly x’s 4 weeks, results report to IPCO.- Proper Social Distancing Audit added to safety committee “Facility Environmental Observation” checklist, to be performed quarterly by Safety Committee Designee and results reported to QIC- Education regarding this survey and its POC will be presented by ADON, DNS and IPCO via Zoom prior to 1/23/21 for LNs. Meeting will be recorded and distributed to all LN staff via email.4) Corrective actions will be monitored to ensure the alleged deficient practice will not reoccur:- IPCO will review PPE DON/DOFF audits and report findings to QAPI for review and follow up for PDSA cycle of learning. Audit finding reported for 4 weeks.- Individual education will be provided with staff if deficient practice is noted during audits.- If deficient practices continue to be noted after 4 weeks, will continue audits for additional timeframe to be determined and report to QAPI.- HR to report PPE DON/DOFF Return Demonstration Competency Findings monthly to QIC for review and follow up at QAPI for 6 months- QIC to review Safety Committee Observations for PPE DON/DOFF and Social Distancing findings to QAPI for follow up for 6 months.5) DNS and Administrator are responsible for this POC6) Completion date: 1/23/21C. Resident mask use and social distancing. 1.) Corrective action for the residents affected by the alleged deficient practice: - All affected residents noted to be without a mask had been (and currently continue to be) tested weekly for COVID-19 and monitored Q shift for s/sx of COVID -19 by LN. 2.) Corrective action taken for those residents having the potential to be affected by the alleged deficient practice: - It was determined that all residents had the potential to be affected by this alleged deficient practice. - We have no current residents with COVID-19.- All residents were offered a face mask – 12/23 and continue to be offered every shift. - Signage will be posted in the dining room to encourage social distancing by IPCO. - RCMS will review dining furniture spacing to promote social distancing. 3.) Measures/systematic changes put in place to assure the alleged deficient practice does not reoccur:- RCMs will review dining furniture spacing and adjust as needed to promote social distancing. - Task created in POC for Q shift charting on resident social distancing. - Task created in POC for Q shift charting on resident mask acceptance/refusal.- COVID care plan created to reflect resident mask use and social distancing. - Infection prevention rounds checklist created to include monitor social distancing and resident mask use.- Education regarding this survey and its POC will be presented by ADON, DNS and IPCO via Zoom prior to 1/23/21 for LNs. Meeting will be recorded and distributed to all LN staff via email.4.) Corrective actions will be monitored to ensure the alleged deficient practice will not reoccur: - Administrator will pull PCC reports to review charting completion on new POC tasks- daily in stand up Mon-Fri. - Care plans will be updated by RCM to reflect resident mask use and social distancing.- Infection prevention rounds will be conducted by the safety committee, COVID prevention team, Nurse Management and/or other designees as assigned at least weekly x 4 weeks.- Individual education will be provided with staff if deficient practice is noted during audits.- If deficient practices continue to be noted after 4 weeks, will continue audits for additional timeframe to be determined and report to QAPI.5.) DNS and Administrator are responsible for the POC.6.) Completion date: 1/23/21D. Dwell times and PPE disinfections1.) Corrective action for the residents affected by the alleged deficient practice:- No residents affected by the alleged deficient practice. 2.) Corrective action taken for those residents having the potential to be affected by the alleged deficient practice: - All residents have the potential to be affected by the deficient practice. 3.) Measures/systematic changes put in place to assure the alleged deficient practice does not reoccur:- Education on contact time for disinfectants will be provided to all departments by IPCO.- Educated all screeners on procedure and frequency required of sanitizing thermometer - 12/23 by Administration.- PPE DON/DOFF education as noted previously in POC. - Will distribute: Sparkling Surfaces, Clean Hands, Closely Monitoring Residents, Keep COVID-19 out! and Lessons educational videos to all staff via Relias. - Created master list of facility cleaners, dwell times and appropriate use - posted in common areas and distributed via email to all staff. - Master list of facility cleaners updated by IPCO when disinfectants change. - IPCO will create procedure on reusable PPE storage and sanitation, to include dwell times of disinfectants. - Will distribute PPE storage and sanitation procedure via Relias to all staff. - PPE DON/DOFF audit sheet created by IPCO.- Created infection prevention rounds checklist. - Education regarding this survey and its POC will be presented by ADON, DNS and IPCO via Zoom prior to 1/23/21 for LNs. Meeting will be recorded and distributed to all LN staff via email.4.) Corrective actions will be monitored to ensure the alleged deficient practice will not reoccur: - Infection prevention rounds include: staff knowledge of appropriate use of disinfectants. - Infection prevention rounds include: screeners appropriately sanitizing thermometers. - Infection Prevention rounds include: PPE storage audits. - Infection Prevention rounds include: DON/DOFF audits.- Infection prevention rounds will be conducted by the safety committee, COVID prevention team, Nurse Management and/or other designees as assigned at least weekly x 4 weeks.- Individual education will be provided with staff if deficient practice is noted during audits.- If deficient practices continue to be noted after 4 weeks, will continue audits for additional timeframe to be determined and report to QAPI.5.) DNS and Administrator are responsible for this POC.6.) Completion date: 1/23/21
A COVID-19 Infection Control Survey and a COVID-19 Confirmed Facility Review were conducted by the Oregon State Survey Agency on 12/3/20 to 12/4/20.
Total residents: 105
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 Revisit Survey was conducted by the Oregon State Survey Agency on 2/4/21.
Total Residents: 101
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OAR 411-086-0110 Nursing Services: Resident Care
Refer to F684
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OAR 411-086-0330 Infection Control and Universal Precautions
Refer to F880
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