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Scope: Widespread
Severity: Immediate jeopardy to resident health or safety
Citation date: April 24, 2020
Corrected date: May 19, 2020
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the COVID-19 Infection Control Focus Survey, complaint #NY 352, it was determined that for three of three residential units, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of COVID-19. The facility staff failed to consistently follow infection control precautions for residents on standard and droplet precautions potentially resulting in cross contamination for 89 residents not identified as having COVID-19. Specifically, two staff members were observed exiting the rooms of two residents (Residents #3 and #4) that had COVID-19 without removing (doffing) Personal Protective Equipment. The staff members either entered the room of a resident that did not have COVID-19 or continued to deliver meal trays without putting on (donning) new Personal Protective Equipment. Additionally, the facility did not protect three residents (Residents #6, #7, and #9) that were asymptomatic and did not have COVID-19. All three residents were residing in rooms with residents that had COVID-19. This resulted in Immediate Jeopardy to resident health and safety that is widespread. This is evidenced by the following: The facility COVID-19 Personal Protective Equipment (PPE) Use policy, revised 4/15/20, included to wear the same gown when interacting with more that one resident known to be infected with the same infectious disease and are housed in the same location (i.e. COVID-19 residents residing in an isolation cohort). The facility Outbreak Management policy, created 3/24/20, revealed that current recommendations are to isolate in place when a private room is not available. Roommates of isolated residents might already be exposed, it is generally not recommended to separate them in this scenario. (Center Disease Control, (MONTH) 2020) Review of the Center for Medicare and Medicaid Services (CMS) COVID-19 Long-Term Care Facility Guidelines, dated 4/2/20, included full PPE should be worn per Centers of Disease Control (CDC) guidelines for the care of any resident with known or suspected COVID-19 per CDC guidance on conservation of PPE. Long-Term Care facilities should separate residents who have COVID-19 from residents who do not or have unknown status. 1. a. Resident #4 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 3/24/20, revealed the resident had moderately impaired cognition. Review of Resident #4's medical record revealed the resident was positive for COVID-19 on 4/9/20. During a continuous observation conducted on 4/21/20 at 5:50 p.m., Certified Nursing Assistant (CNA) #1 was observed providing hands-on feeding assistance to Resident #4. CNA #1 was wearing the following PPE: a one-piece yellow protective suit, a surgical mask, a face shield, and two pairs of gloves. There was a sign on Resident #4's door that directed to see the nurse. During the observation, CNA #1 touched the outer surface of the face shield with her gloved hand. After providing feeding assistance, CNA #1 exited Resident #4's room with the meal tray in her gloved hands. CNA #1 emptied the meal tray into a large, red trash bin outside of Resident #4's room. CNA #1 then removed her first pair of gloves, picked up the empty meal tray, walked down the hall, and returned the empty tray to the meal transport cart that was holding other resident meal trays that had not been passed yet. CNA #1 then returned to the red trash bin, removed and discarded her second pair of gloves. CNA #1 proceeded down the hall across from the resident's room, accessed the keypad lock to enter the clean utility room, and washed her hands. At 5:57 p.m., CNA #1 collected another meal tray from the cart and proceeded to the room of Resident #5. CNA #1 was observed in Resident #5's room for ten minutes providing hands on feeding assistance. CNA #1 did not cleanse, disinfect, or doff her yellow protective suit during the observation. Review of Resident #5's medical record revealed the resident was not tested for COVID-19 and was asymptomatic (showing no symptoms). When interviewed on 4/21/20 at 6:10 p.m., CNA #1 stated that staff wear the same yellow protective suit to care for all residents. CNA #1 said she should have wiped her suit down when leaving Resident #4's room but had not done so. b. Resident #3 has [DIAGNOSES REDACTED]. The MDS Assessment, dated 4/2/20, revealed the resident had moderately impaired cognition. Review of Resident #3's medical record revealed that the resident was positive for COVID-19 on 4/15/20. In an observation on 4/21/20 at 5:20 p.m., Resident #3 was in their room. There was a sign on the door that directed to see the nurse and an isolation set up on the door which contained gloves. CNA #2 entered the resident's room wearing a yellow one-piece protective suit and a mask with no gloves to deliver the resident's dinner tray. CNA #2 washed her hands with soap and water prior to leaving the room, and then went to the food cart and picked up another resident's tray and proceeded to pass trays on the unit. When interviewed at that time, CNA #2 said that Resident #3 has COVID-19. She said that staff wear the same yellow protective suits when caring for all residents and staff do not need to change the suits. She said the isolation set-up was for the last resident that was in the A bed. When asked about wearing gloves, she said that she washed her hands with soap and water. CNA #2 did not cleanse, disinfect, or doff her yellow protective suit during the observation. 2. a. Resident #1 has [DIAGNOSES REDACTED]. The MDS Assessment, dated 3/20/20, revealed that the resident was cognitively intact. Review of Resident #1's medical record revealed that the resident was positive for COVID-19 on 4/18/20. In an observation on 4/21/20 at 4:15 p.m., Resident #1 was observed in a semi-private room with the door open. Resident #1 was in bed with their mouth wide open, snoring, and was not wearing a mask. The resident's roommate (Resident #7) was in their bed with no mask. The curtain between the beds was pulled partially covering about 3/4 of the length of the beds. The sign on the door directed to see the nurse. Review of Resident #7's medical record revealed that the resident was not tested for COVID-19 and was asymptomatic. When interviewed by telephone on 4/22/20 at 12:20 p.m., the Registered Nurse (RN) Regional Director of Clinical Services said that the facility was moving Resident #1 to another room on the second floor that day. In an observation on 4/23/20 at 11:27 a.m., Resident #1 and Resident #7 remained in the same room together. b. Review of the facility's Infection Surveillance Sheet revealed that Resident #8 tested positive for COVID-19 on 4/13/20. In an observation on 4/23/20 at 12:09 p.m., the door to Residents #8 and #9's room had a droplet precaution sign. Both Resident #8 and Resident #9 were in their beds, and neither resident was wearing a mask. Review of the medical record for Resident #9 revealed that the resident was not tested for COVID-19 and was asymptomatic. 3. Resident #2 has [DIAGNOSES REDACTED]. The MDS Assessment, dated 4/1/20, revealed the resident had moderately impaired cognition. Review of Resident #2's medical record revealed that the resident was positive for COVID-19 on 4/20/20. In an observation on 4/23/20 at 12:27 p.m., the door to Resident #2's room had a droplet precaution sign. Both Resident #2 and Resident #6 were in their beds, and neither resident was wearing a mask. Review of Resident #6's medical record revealed that the resident was not tested for COVID-19 and was asymptomatic. When interviewed on 4/21/20 at 5:50 p.m., Licensed Practical Nurse (LPN) #1 said that resident's that are positive for COVID-19 have signs on their door that directs to see the nurse. She said that staff should put a blue gown over the yellow one-piece protective suits before entering resident's rooms that are COVID-19 positive. She said the blue gown should be removed before leaving the resident's room. In an interview on 4/24/20 at 9:23 a.m., the RN Regional Director of Clinical Services said that Residents #6, #7, and #9 had not been tested for COVID-19 and were asymptomatic and presumed negative. She said the facility was following CDC guidelines which recommended no movement of residents who had likely had an exposure to COVID-19. She said the privacy curtain should be pulled when a resident that is positive for COVID-19 rooms with a resident that is negative for COVID-19. She said the rooms allow for a 6-foot distance between the residents. She said both residents should wear masks, and the entire room should be placed on droplet precautions. She said she was not aware if the guidance for cohorting residents had changed. The facility's allegation of compliance to remove the Immediate Jeopardy, dated 4/24/20, included the following: a. Staff would be educated on infection control practices including, but not limited to, preventing cross contamination with an emphasis on factors that can lead to cross contamination, infection control practices, importance of appropriate PPE, implementing proper PPE with return demonstrations, and policies related to COVID-19. Proper signage on COVID-19 rooms doors that direct staff on the type of PPE needed and procedure for donning and doffing. b. Move residents that are not positive for COVID-19 so that they are no longer residing with residents that are positive for COVID-19. The Immediate Jeopardy was removed on 4/25/20 based upon surveyor observations and verifications which included the following: a. Observations revealed that Residents #6, #7, and #9 no longer reside in rooms with COVID-19 residents. b. Observations revealed that all COVID-19 residents had an isolation set up hanging on the door that was stocked with PPE and appropriate signage that directed staff on type of PPE needed and procedure for donning and doffing. Staff were removing all PPE prior to exiting a COVID-19 room (exception cleaning face shield with Clorox wipes) and performing hand hygiene. c. Staff were educated on infection control policies and procedures related to COVID-19 including PPE requirements, preventing cross contamination, donning and doffing PPE, and hand hygiene. The facility provided a copy of the power point used for education and signature sheets for those that completed the education. As of 4/25/20, 60 percent of the staff had been educated with a plan to educate all staff prior to working their next scheduled shift. On 4/27/20, greater than 90 percent of the staff had been educated with a plan to continue to educate all staff and new hires. (10 NYCRR 415.19) | Plan of Correction: ApprovedMay 24, 2020 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** How the corrective action will be accomplished for any resident affected by deficient practice: Upon notification Resident #6, #7, #9 were relocated to separate rooms and evaluated by the APRN with no significant changes in assessment How we identified other residents/areas that could potentially be affected: A full house audit was completed, a COVID unit was created on the 3rd floor. All residents were co-horted based on clinical symptoms as they relate to Covid-19 QA committee was convened identifying root cause and analysis on plan formulation relating to infection control practices related to COVID-19 management, protocol, providing oversight on staff?s compliance on PPEs and environmental practices. The committee also: A. Assessed/discussed the causative factors that have contributed to the issues identified in the deficiencies. B. Identified the specific steps/interventions undertaken to eliminate and correct the causative factors identified. C. Identified the surveillance system(s) that the facility will implement for the above deficiencies, that alerts the QA committee to further deficient practices in this area. D. Monitor and review the system so that prompt actions can be taken to correct identified concerns. Quality Assurance Causative Factors: 1. Employees not following established PPEs for management of COVID-19 2. COVID-19 new infectious process nationwide; new regulations constantly changing with CDC 3. Nurse managers or supervisors not providing adequate oversight related to PPEs adherence to established guidelines. 4. Limited nursing leadership oversight, supervision and direction CDC guideline changed on cohorting changes; policy not revised to reflect the change. 5. New emerging changes related to COVID-19 management. Measures to ensure were/will be put into place to assist this area of concern: Corporate policies COVID-19 Environmental Management, COVID-19 Outbreak Management, COVID-19 Prevention were reviewed, the COVID-19 Outbreak Management policy was updated on 4/24/20 to reflect the updated CDC guidelines The staff educator or designee educated staff on donning and doffing PPE, cross-contamination, including during meal pass, and COVID-19 policies and procedures. PPE donning and doffing competency was completed on all scheduled staff. Those not completed have been notified via phone and/or mail that they are removed from the schedule until they complete the required competencies. All new hires will be educated on the above process in new employee orientation Residents with COVID- 19 positive [DIAGNOSES REDACTED]. DIRECTED PLAN OF EDUCATION: Consultant/Instructor: Yetunde Fasusi, RN, MSN Dates of Training Sessions: To be commenced effective (MONTH) 12, 2020 and ongoing Targeted staff: Facility Nursing Leadership to include, DON, ADON, Unit Managers and Supervisors and Nursing Staff (RNs, LPNs), nursing assistants, agency staff, contractors Objectives All above staff will understand the significant effect of this deficiency All the above staff will understand their responsibilities in regards to contributing factors to the deficiency. All above staff will understand and verbalize importance of adherence to infection control practices and COVID-19 management according to applicable rules. Employees will understand utilizing appropriate PPEs in management of COVID-19 residents. Employees will understand prevention of cross contamination of infection with COVID-19 All the above staff will understand policy and procedure related to COVID-19 cohort Course Outline Review of regulation relating to COVID-19 management per CDC Review of Statement of Deficiency; review Root Cause and Contributing Factors Review of COVID-19 Policies and Procedures Training of employees on COVID-19 management; wearing of PPES Co-horting protocol for COVID-19 The interdisciplinary team will conduct unit rounding to identify and correct areas of improvement relating to adherence to PPEs and infection control practices Unit managers, nursing supervisors or designee will provide oversight related to nursing staff adherence to infection control guidelines Corrective action will be initiated upon identification. Evaluation/auditing tool will be utilized to monitor effectiveness of these interventions. Administrator and Director of Nursing services will oversee effectiveness of above interventions. Review of audit processes will be completed by facility?s Administrator / Director of Nursing. The Regional Nurse will perform review of above implementation and provide feedback on plan of correction. How the concern will be monitored and title of person responsible for monitoring: The Administrator or designee will conduct environmental rounding 5x/week for 4 weeks and then weekly x 3 months Unit manager or designee will complete weekly PPE observational audits of 10 staff weekly x 4, bi-weeklyx2 then monthly x 3. DON or designee will audit cohorting and discontinuation of isolation weekly. The Quality Assurance Committee will determine the continuation of audits. Findings will be reported to the Quality Assurance committee monthly, modifications and continuance of the audits will be determined by this committee Responsible party: DON |