The Grand Rehabilitation and Nursing at Barnwell
May 21, 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: May 21, 2020
Corrected date: June 26, 2020

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not 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. Specifically, the facility did not follow the cohorting requirements documented in the Dear Administrator Letter (DAL) dated (MONTH) 29, 2020 for 4 (Resident #'s 4, 8, 9, and #10) of 10 residents reviewed. Persons Under Investigation for COVID-19 (Resident #s 4 and 8) were cohorted with asymptomatic Residents #9 and #10. Additionally, the facility did not ensure there were transmission-based precautions signs on the doors of Resident #'s 4 and #8. Also, the facility did not ensure a glucometer was cleaned and disinfected after being used on Resident #4. This is evidenced by: Executive Order 202.11 dated (MONTH) 27,2020 documented the following: Any guidance issued by the New York State Department of Health related to prevention and infection control of COVID-19 shall be effective immediately and shall supersede any prior conflicting guidance issued by the New York State Department of Health and any guidance issued by any local board of health, any local department of health, or any other political subdivision of the State related to the same subject. The New York State Department of Health Dear Administrator Letter (DAL) dated (MONTH) 29, 2020 documents the following: As care pertains specifically to COVID-19, state and federal rules and regulations require nursing homes must adhere to appropriate safety measures including, but not limited to: Having protocols to separate residents into cohorts of positive, negative, and unknown as well as separate staffing teams to deal with COVID-positive residents and non-positive residents. In order to effectuate this policy, nursing home facilities should transfer residents within a facility, to another long-term care facility, or to another non-certified location if they are unable to successful separate outpatients in individual facilities. Finding 1: The facility did not ensure residents were separated into cohorts of COVID-19 infection status of positive, negative, and unknown. The Policy and Procedure (P&P) for Infection Control: Guidance on COVID-19 (formerly Coronavirus) dated 4/2020 documented staff were to ensure residents with symptoms of suspected COVID-19 or other respiratory infection (such as fever, cough) were to be placed on Droplet and Contact precautions. Residents were also to be placed in a private room with a dedicated bathroom when possible and if not, the facility was to cohort residents with same presentations or confirmed diagnosis. During an observation on 5/20/20 at 11:30 AM, Resident #s 4 and 10 were residing in the same room. The facility's Resident Roster documented Resident #s 4 and 10 were residing in the same room. During an observation on 5/20/20 at 11:30 AM, Resident #s 8 and 9 were residing in the same room. The facility's Resident Roster documented Resident #s 8 and 9 resided in the same room. Resident #4: Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- an assessment tool) dated 5/20/20 documented the resident was cognitively intact and able to make needs known. A progress note dated 5/17/20 at 8:41 AM, documented oxygen saturation of 91-93% on room air and a temperature of 103.1 degrees. A progress note dated 5/17/20 at 6:34 PM, documented a physician's orders [REDACTED]. Resident #10: Resident #10 was admitted to the facility with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident was cognitively intact and able to make needs known. A progress note dated 5/6/20 at 12:05 PM, documented the resident tested negative for COVID-19. Resident #8: Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident had severe cognitive impairment. A progress note dated 5/17/20 at 1:40 PM, documented the resident had chills, a fever of 101.6 degrees. A progress note dated 5/17/20 at 6:58 PM, documented a physician's orders [REDACTED]. Resident #9: Resident #9 was admitted to the facility with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident was cognitively intact and able to make needs known. A progress note dated 5/6/20 at 12:10 PM, documented the resident tested negative for COVID-19. During an interview on 5/20/20 at 4:54 PM, the Regional Administrator stated residents with different COVID statuses should not have been residing in the same room. During an interview on 5/20/20 at 5:13 PM, the Director of Nursing (DON) #1 stated residents who had an unknown or suspected COVID-19 status should not have been assigned to live in the same room with residents who were asymptomatic and have tested negative for COVID-19. During an interview on 5/20/20 at 5:20 PM, the Administrator stated that cohorting residents was supposed to be done in 3 categories: positives, negatives, and unknowns or suspected together. During an interview on 5/21/20 at 11:00 AM, The DON #2 stated residents should have been cohorted according to their COVID-19 status, positives together, negatives together, and unknowns or suspected. DON #2 also stated residents should have been in private rooms if possible and if private rooms were not possible, then residents with statuses of unknown or suspected COVID-19 should be placed together. Finding 2: The facility did not ensure there were signs on the room doors of symptomatic residents pending test results for COVID-19. The P&P for Droplet Precautions dated 3/2019 documented droplet precautions were to be used for specified residents known or suspected to be infected by microorganisms transmitted directly from the respiratory tract of the susceptible mucosal surfaces of another resident. As soon as precautions were implemented, a Stop Report to Nurse sign was to be placed on the resident's door and remain in place until precautions were discontinued. During an observation on 5/20/20 at 11:30 AM, there was not a Stop Report to Nurse sign placed on the doors for Resident #s 4 and 8's doors. Resident #4: A progress note dated 5/17/20 at 8:41 AM, documented oxygen saturation of 91-93% on room air and a temperature of 103.1 degrees. Resident #8: A progress note dated 5/17/20 at 1:40 PM, documented the resident had chills and a fever of 101.6 degrees. A progress note dated 5/17/20 at 6:58 PM, documented a physician's orders [REDACTED]. During an interview on 5/20/20 at 11:40 AM, Licensed Practical Nurse (LPN) #2 stated Residents #s 4 and 8 were not placed on droplet precautions because their test results were pending, so they were not yet identified as being positive. During an interview on 5/20/20 at 12:05 PM, Health Assistant (HA) #2 stated the sign on the door and the isolation carts indicated which residents were COVID-19 positive and Residents #s 4 and 8 were considered negative. During an interview on 5/20/20 at 12:20 PM, Registered Nurse (RN) #1 stated that, if there was no sign on the door or an isolation cart outside the room, then that resident was considered negative. During an interview on 5/20/20 at 5:13 PM, DON #1 stated the expectation was for staff to treat all unknown or suspected residents as COVID-19 positive, and that signs and isolation carts should have been placed on Resident #s 4 and 8's rooms to alert and instruct all staff prior to entering the room. Finding 3: The facility did not ensure a glucometer was clean and disinfected after each use. A P&P titled Cleaning/Disinfecting of Glucometer dated 3/2020 documented durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident. Glucometer cleaning should take place prior to, and immediately after each use to prevent the spread of pathogens from blood or body fluids. Resident #4: A progress note dated 5/20/20 at 12:07 PM, documented Resident #4 was to receive insulin per sliding scale with no coverage needed. During an observation on 5/20/20 at 12:51 PM, LPN #2 performed a blood glucose test on Resident #4. LPN #2 removed her gloves and exited the resident's room, placed the glucometer on the medication cart prior to disinfecting the glucometer, and left the medication cart to perform other tasks. During an interview on 5/20/20 at 12:54 PM, LPN #2 stated the glucometer used on Resident #4 was not specific to that resident and was used on other residents on the unit. LPN #2 stated all multi-use devices were supposed to be disinfected before and after resident use and prior to returning it to the medication cart and did not know why she did not disinfect the device. During an interview on 5/21/20 at 11:00 AM, the DON #2 stated staff were supposed to wipe down the glucometers per manufactures instructions after each use and before it was returned to the medication cart. 10 NYCRR 415.19(b)(1)

Plan of Correction: ApprovedJune 1, 2020

Corrective Action for those residents/ areas affected:
Resident #4- was immediately moved with Resident# 8 since both residents were pending results and both residents had suspected COVID-19 due to their symptoms.
Resident #4 and resident #8 were also placed on Droplet Precautions and a ?Stop Report to Nurse? sign was placed on resident?s door and will remain until precautions are discontinued.
Resident #4 ? the Glucometer was immediately disinfected and Policy and Procedure was re-educated for staff member #2 LPN to wipe down the glucometer with disinfectant wipes after each use and before returning it to the cart.
#2 LPN- was educated on proper PPE ? ?Droplet Precautions? and residents who are getting tested for COVID-19 and are symptomatic should be considered positive and Droplet Precautions should be placed and discontinued after a negative test result.
HA #2 ? Educated on proper PPE use and PPE policy and procedure, including ?Stop Report to nurse? signage and when carts will be located next to residents room.
Resident #9 resident #10 were immediately moved and placed in the same room since both tested negative.
Corrective Action taken for other residents with the potential to be affected:
All residents in the facility have the potential to be affected. The infection Control Nurse will audit 10 random residents? room and check for proper PPE usage and if residents are co-horted correctly. Any staff member who fails to identify when and how to use PPE will be required to practice until they can pass a competency test with the DON. Nursing staff will be educated on proper co-horting residents. The infection control nurse will review the policy and procedure on infection control and ensure all staff are educated and educated on the COVID-19 policy and procedure protocol. All nursing LPN?s and RN?s will get re-educated on Cleaning and Disinfecting Glucometers. The Nurse Managers will randomly audit LPN?s on their unit twice a week on the proper disinfecting glucometers per the policy after each use and before it returns to the nurse?s cart.
Systemic Measures to prevent reoccurrence:
Review Policy and procedure for all staff on infection control PPE usage, including proper signage on residents rooms whom are positive or may be positive due to symptoms of COVID- 19.
Implement additional audits on Infection control which will focus on wiping and disinfecting Glucometers, audits will be added to QA monitoring.
Infection Control nurse will monitor all units on proper cohort residents and the proper use of PPE and infection control usage, weekly audits will be conducted times 4 weeks and will be added to QA monitoring.
Quality Assurance Monitoring:
Infection control audit will be audited weekly times 4 weeks then monthly by the infection control nurse which will include cohorting the residents into their proper rooms, which will be included in the morning meeting review.
Any concerns will be corrected immediately, PPE audit will be done on each unit daily for 1 week and then audited weekly x4 weeks
The PPE and infection control audit will be reviewed by the QA committee monthly x 6 months, then as directed by the committee
All nursing lpn?s and RN?s will get audited on correct policy and procedures for disinfecting Glucometers. Nurse managers will audit 2 lpns x1 week for 4 weeks then monthly x6 months.
Morning meeting will include all positive COVID-19 and possible COVID-19 residents have the proper signage posted on the residents doors, ?Stop Report to Nurse? the nurse managers will audit 5 residents rooms a day to ensure compliance then 10 rooms a week then 10 rooms monthly x 6 months.
Responsible person: Director of Nursing