Based on observation, interview and record review it was determined the facility failed to maintain appropriate infection control precautions during staff observations for 3 of 3 wings reviewed for COVID-19. This placed residents at risk for infection. Findings include:
The facility's Policy and Procedure on Infection Prevention and Control Manual Interim Policy for Suspected or Confirmed Coronavirus (COVID-19) dated 10/2020 included measures to implement:
All staff will practice universal source control for face masks and eye protection. If the Health Care Provider (HCP) touches or adjusts their eye protection during care they must immediately perform hand hygiene. Hand hygiene before and after all patient contact with infectious material and before and after removal of PPE, including gloves. Staff will be provided appropriate PPE at the beginning of each shift to be worn during work hours, and social distancing was defined as at least six feet apart from others when in the facility.
Resident 1 was admitted to the facility in 10/2020 with diagnoses including convulsions (sudden or violent involuntary body movement) and lung disease.
The 10/2020 care plan indicated Resident 1 was on 14-day special droplet precautions (PPE: gowns, gloves, mask, face-shield or goggles).
On 10/30/20 at 1:15 PM Staff 1 (NA) was observed donning PPE prior to entering Resident 1's room, which was located on the south wing. Staff 1 was then observed doffing PPE inside Resident 1's room, but failed to wash or sanitizing her hands after removing her gloves. Staff 1 proceeded to walk down the hall touching communal items. The surveyor stopped Staff 1 in the hallway and asked about cross-contamination. Staff 1 acknowledged she failed to wash her hands after providing resident care. During additional observations Staff 1 was also observed walking on the west and north wings adjusting her goggles without sanitizing hands afterward.
On 10/30/20 at 1:30 PM Staff 2 (Agency CNA) was observed on the designated isolation unit located on the south wing wearing her goggles on her forehead and touching her face mask without washing or sanitizing her hands. Staff 2 stated she was aware of infection control measures but continued to adjust her goggles and touch her face mask multiple times during the interview. The surveyor asked Staff 2 to sanitize her hands. Staff 2 further stated "36 minutes ago" she gave a resident on isolation precautions a shower but did not sanitize the communal shower room. Staff 2 indicated she should have cleaned the shower room right after but failed to do so.
On 10/30/20 at 1:35 PM Staff 3 (CMA) was observed multiple times walking from the designated isolation unit, which was located on the south wing, to the north wing and standing next to the medication cart wearing her goggles on her forehead and touching her face mask without washing or sanitizing her hands. Staff 3 confirmed touching her goggles and face mask and acknowledged she failed to sanitize her hands.
On 10/30/20 at 1:45 PM Staff 4 (Scheduling Coordinator) was observed on the designated isolation unit located on the south wing standing in the hallway not wearing a face shield or goggles. Staff 4 was observed talking with Staff 5 (CMA) and not following social distancing requirements. Staff 4 stated Staff 5 was trying to get better at wearing his goggles outside his office, but he often forgot until being reminded and he should have been farther away from her.
On 10/30/20 at 1:46 PM Staff 5 was observed on the designated isolation unit located on the south wing standing in the hallway not wearing a face shield or goggles. Staff 5 was observed talking with Staff 4 and not following social distancing requirements. Staff 5 stated she should have been wearing a face shield or goggles but was "in a hurry." Staff 5 also acknowledged she was not following social distancing requirements.
On 10/30/20 at 1:50 PM Staff 6 (CNA) was observed leaving the staff breakroom located on the west wing walking past the nurses station with Staff 7 (CNA), and not following social distancing requirements. Staff 6 was observed not wearing goggles or a face shield. Staff 6 stated she was not sure if she was required to wear a face shield or goggles when she was not providing resident care. Staff 6 also acknowledged she was not six feet apart from Staff 7.
On 10/30/20 at 1:51 PM Staff 7 was observed leaving the staff breakroom located on the west wing walking past the nurses station with Staff 6 and not following social distancing requirements. Staff 7 was observed not wearing goggles or a face shield. Staff 7 stated she did not think wearing her goggles was required because she was attending a safety meeting. Staff 7 acknowledged she was not six feet apart from Staff 6 and further stated the facility had a storage area in the dining room for staff to store their goggles and face shields but she took her goggles home.
On 10/30/20 at 2:40 PM the surveyor discussed staff observations with Staff 8 (Administrator) and Staff 9 (DNS). Staff 8 and Staff 9 both acknowledged staff failed to follow infection control practices in all three wings.
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OAR 411-086-0330 Infection Control and Universal Precautions
Refer to F880
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