A COVID-19 Focused Infection Control Survey was conducted by the Oregon State Survey Agency 11/18/20 through 11/23/20.
A deficiency was cited.
Total residents: 42
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 1/14/21 to 1/19/21.
The facility was found to be in compliance with 42 CFR ยง483.80.
Total residents: 48
Based on observation, interview and record review it was determined the facility failed to follow EPA guidelines for disinfection contact times (the time the disinfectant should remain wet on the surface to ensure efficacy) for 3 of 3 halls and failed to follow manufacturer's recommendations for glucometer (a blood sugar monitoring device) disinfection for 2 of 3 halls reviewed for infection control. This placed residents at risk for infections. Findings include:
1. On 11/18/20 observations of all three resident halls found six different disinfection wipes with varying contact times available to staff and the most readily available was Multi-Use wipes with a contact time of four minutes.
On 11/18/20 at 2:15 PM Staff 1 (CNA) was asked about disinfection and contact times. Staff 1 stated she used disinfecting wipes to clean the medication cart a couple times per shift but was not aware of product contact times.
On 11/18/20 at 2:43 PM Staff 2 (CNA) was asked about disinfection of shared vital signs equipment and contact times. Staff 2 stated the CNAs cleaned the equipment after each use. Staff 2 added she used the Multi-Use wipes and they required four minutes of contact time. Staff 2 explained she wiped down the equipment, set the item aside and did something else until four minutes time passed and then the equipment could be used again. Staff 2 did not indicate she monitored the equipment to ensure it remained wet for the full four minutes of required contact time.
On 11/18/20 at 3:13 PM Staff 3 (CNA) was observed to exit a resident room on Wing Three and obtain a Multi-Use wipe, passed the wipe over a thermometer and set it in the equipment basket before the thermometer was disinfected.
On 11/18/20 at 3:18 PM Staff 3 was asked about cleaning reusable equipment and stated he wiped down the equipment using wipes and let dry for four minutes before reusing. Staff 3 did not indicate he monitored the equipment to ensure it remained wet for the required contact time.
On 11/18/20 at 4:10 PM Staff 4 (CNA) was asked about disinfection of her face shield and stated she used alcohol prep pads (small squares of gauze impregnated with alcohol). Staff 4 did not indicate she was aware of the contact time required to disinfect her face shield. Staff 4 was asked about disinfection of vital sign equipment and stated she used whatever we have available. When asked about contact times Staff 4 stated after disinfection the contact time is the time you had to wait to use the equipment again. Staff 4 did not indicate she monitored the equipment to ensure it reamined wet for the required amount of time.
On 11/18/20 at 4:26 PM Staff 5 (LPN) was asked about disinfection of computers and she stated the person who used the computer should disinfect it. Staff 5 added the nurses cleaned the nursing station and wiped down the counters. Staff 5 stated she used bleach wipes to wipe down items. Staff 5 was asked about contact times and stated it is the time you had to leave it after cleaning before you could use the item.
On 11/18/20 at 4:46 PM Staff 6 (LPN) was asked about disinfection of face shields and stated she used a Multi-Use wipe to wipe down the face shield and dried the shield with a paper towel. She did not describe contact time in her process.
No staff interviewed defined contact time as the time the product must remain wet on the surface to fully disinfect.
On 11/18/20 at 5:00 PM staff's understanding of disinfectant product use and contact times was discussed with Staff 7 (Corporate RN). Staff 7 stated the product most used was the Multi-Use wipe and required four minutes of contact time. When asked about staff's understanding of contact time, she stated staff were educated and added the facility would go through and provide re-education for staff.
2. Manufacturer's guidance for disinfection of the Evencare glucometer recommended Microkill with the red top and Clorox Bleach (disinfection products) wipes both of which were present in the facility.
On 11/18/20 at 4:26 PM Staff 5 (CNA) was asked about disinfection of glucometers and stated she would use a bleach wipe or whatever we have available. Staff 5 was unable to explain what product contact time meant.
On 11/18/20 at 4:49 PM Staff 6 (LPN) was observed to perform a blood sugar check on Resident 4. Staff 6 used a Multi-Use wipe and briskly wiped down the glucometer for approximately ten seconds. Staff 6 did not ensure the glucometer remained wet for the required four minutes. Staff 6 was asked about contact time for the wipe and stated it worked in four minutes and the surface was not clean until then.
Staff interviewed were not able to define contact time or the recommended product for glucometer disinfection.
On 11/18/20 at 5:00 PM staff observations and understanding of disinfectant product use and contact time for glucometer disinfection was discussed with Staff 7 (Corporate RN). Staff 7 stated the product most used was the Multi-Use wipe and required four minutes of contact time for efficacy. Staff 7 added staff were educated and the facility would go through and provide re-education for staff.
F 880 1. Staff on 100, 200 and 300 halls were immediately educated on dwell time meanings and EPA guidelines. 2. Residents are at risk for being affected by potential exposure to pathogens due to ineffective disinfection of equipment and environment. 3. A. Facility replaced multiple wipe with only 2 disinfectants: EPA approved disinfectant per manufacturer recommendation for glucometers and EPA approved disinfectant for all other hard surfaces 12/14/2020B. Infection Preventionist to educate nursing and therapy staff on disinfectants to include: dwell time, appropriate surfaces to disinfect, when to disinfect, use of PPE (gloves) and safe storage. C. DNS or designee to educate nursing staff on: cleaning frequency for nurses stations, medication/treatment carts, computers and kiosks. D. Administrator or designee to re-educate facility staff on face shield cleaning and storage, to include dwell time and location of supplies. E. Infection Preventionist to educate LNs on disinfection of glucometers to include dwell time and approved product for the Evencare glucometer.F. Facility staff assigned the following videos in Relias: Sparkling Surfaces, Clean Hands, Closely Monitor Residents, Keep COVID-19 Out! And Lessons. Director of Nursing to monitor staff completion and provide summary to QAPI.4. A. DNS and/or designee to conduct an audit of 30 staff disinfecting opportunities to include face shields, CBG, reusable equipment and DME weekly x 4 weeks, monthly x 3 months and quarterly thereafter. 5. Summary to be presented to QAPI monthly x 3 months and quarterly thereafter to ensure compliance and sustainability Date of substantial compliance: 12/28/2020
A COVID-19 Infection Control Survey and a COVID-19 Confirmed Facility Review were conducted by the Oregon State Survey Agency 11/18/20 through 11/23/20.
Total residents: 42
A deficiency was cited.
Refer to the Form CMS 2567 dated 11/23/20.
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 1/14/21 to 1/19/21.
The facility was found to be in compliance.
Total residents: 48
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OAR 411-086-0330 Infection Control and Universal Precautions
Refer to F880
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