Glens Falls Center for Rehabilitation and Nursing
April 30, 2020 Complaint Survey

Standard Health Citations

FF11 483.80(a)(1)(2)(4)(e)(f):INFECTION PREVENTION & CONTROL

REGULATION: §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 30, 2020
Corrected date: May 18, 2020

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the COVID-19 Infection Control Focus Survey completed on 4/30/2020, the facility did not establish and maintain an Infection Control Program to ensure the health and safety of residents to help prevent the transmission of COVID-19. Specifically, facility staff did not ensure the handling and delivery of laundry was performed in a manner to prevent the spread of COVID-19 infection when facility staff delivering laundry in the facility entered a resident's room that had directions for the use of PPE posted on the room door, wearing PPE (personal protective equipment) required to enter that room with the exception of gloves. Facility staff exited the room without removing PPE or performing hand hygiene and entered another resident's room who did not have directions for the use of PPE posted on their door. This is evidenced by: Review of a facility policy and procedure (P&P) titled COVID-19 Prevention dated 3/24/20 documented employees were to clean their hands according to Centers for Disease Control guidelines, including before and after contact with residents, after contact with contaminated surfaces and after removal of PPE. The finding is: During an observation on 4/30/20 at 10:45 AM, Laundry Aide #1 was on the East resident care unit delivering resident laundry. The Laundry Aide was observed exiting a resident room with a blue sign on the door PPE Required, gown, gloves, face shield or goggles, N95 mask. Door to remain closed, picked up clothing from the cart in the hallway and entered another resident room that did not have a blue sign on the door. The Laundry Aide was wearing a gown, mask, and face shield. Laundry Aide #1 stated the blue sign meant the resident in that room was COVID positive. When asked what she was taught about entering and exiting COVID positive rooms the Laundry Aide stated she didn't have to do anything between rooms but that the housekeepers do all the non COVID rooms and then COVID rooms, I guess that's what I should do. When asked if she touched any surfaces in the COVID positive resident's room when she entered, she stated I opened the closet door and hung up the clothes. During an interview on 4/30/20 at 11:00 AM, Registered Nurse (RN) #1 stated the Laundry Aide should be doffing (removing) PPE including gloves, washing hands, and donning new PPE upon exit from COVID positive room. When informed of the actions of Laundry Aide #1 observed by surveyors, RN #1 stated that the actions were a breach of infection control and staff should not be going in and out of rooms like that. RN #1 remained seated at the desk and did not attempt to immediately stop and reeducate the Laundry Aide who continued down the hall dispersing laundry. During an interview on 4/30/20 at 11:10 AM, the Regional Corporate Educator, RN #2 stated staff should not be going in and out of rooms randomly. Handwashing as well as changing of PPE should be performed upon exit from a Covid positive room. When informed of the actions of Laundry Aide #1, RN #2 stated I will go re-educate her now. At 1:00 PM, RN #2 stated Laundry Aide #1 had attended the training provided to staff regarding proper use of PPE, handwashing and Covid specific training which included preventing the spread of Covid through handwashing, PPE, and entering non Covid rooms first and then Covid rooms systematically so as not to spread [MEDICAL CONDITION] to non-infected residents. Documentation of three trainings that occurred on 3/25/20 and 4/4/20 was provided. RN #2 provided copies of re-education provided to Laundry Aide #1 and other staff today following surveyors report of observations. During an interview on 4/30/20 at 11:15 AM, Laundry Supervisor #2 reported Laundry Aide #1 was the only staff distributing laundry to residents throughout the building today. All staff should be completing tasks in non Covid rooms before entering Covid positive rooms. Staff should handwash and doff PPE upon exiting Covid positive rooms. At 3:30 PM the Laundry Supervisor reported a discussion with Laundry Aide #1 took place about two weeks ago regarding the proper procedure for delivering laundry during the pandemic and Laundry Aide #1 expressed understanding. 10 NYCRR 415.19 (b)(1)

Plan of Correction: ApprovedMay 11, 2020

Laundry Aide #1 was immediately removed from the assignment by the Nurse Manager on 4.30.20 and provided one to one re-education regarding COVID 19, use of personal protection equipment and hand washing. A return demonstration competency was completed. Personal items from affected resident rooms have been removed from rooms for re-laundering by nursing staff on 4.30.20. RN #1 was re-educated regarding the requirements of supervision by the Director of Nursing/Designee on 5.7.20.
An observational audit of staff infection control practices will be completed by the Director of Nursing on 5.7.20 for laundry personnel. Concerns identified will be addressed at the time of observation.
Facility laundry staff will be re-educated by the Director of Nursing/Designee beginning 4.30.20 regarding the requirements of linen handling to prevent the spread of infectious disease, use of PPE and hand hygiene. Laundry staff will not delivery linen to patient rooms during the corona-virus outbreak.
Audits will be completed weekly for 12 weeks by the Director of Nursing/designee to validate staff continue to implement infection control practices including requirements of linen handling, use of PPE and hand hygiene as required. Results of these audits will be brought to the monthly QAPI meeting for 3 months and as needed. The Director of Nursing is responsible for ongoing compliance.
Date of Compliance: 5.18.20