The Grand Rehabilitation and Nursing at Barnwell
May 13, 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 13, 2020
Corrected date: June 26, 2020

Citation Details

Based on observation, interview and record review conducted during the COVID-19 Infection Control Focused Abbreviated Survey completed on 5/12/20, 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, on 2 (Units 4 and 6) of 6 units, staff were observed entering rooms of COVID-19 positive residents, then entering COVID-19 negative residents' rooms without changing PPE or performing hand hygiene in between. This is evidenced by: The policy and procedure (P&P) titled Guidance on COVID-19 (formerly Coronavirus) dated 2/11/20, documented Health Care Providers (HCP) must receive training on, and demonstrate an understanding of, when to use Personal Protective Equipment (PPE). The P&P documented gloves were to be put on upon entry into the patient room or care area and removed and discarded when leaving the patient room or care area, and a clean isolation gown was put on upon entry into the patient room or area and removed and discarded in a dedicated container for waste or linen before leaving the patient room or care area. UNIT 4 During an observation on Unit 4 on 5/11/20 at 2:45 PM, Resident Assistant (RA) #2, who wore a gown, face mask, and gloves, entered and exited resident rooms with and without signs on or next to the door that stated PPE Gowns, Gloves, Face Mask, and Goggles must be worn beyond this point. RA #2 was observed within 6 feet of residents without changing PPE. During an observation on Unit 4 on 5/11/20 from 2:45 PM to 2:55 PM, an Activities Aid (AA) #1 was observed exited a resident room with a sign on the door PPE Gowns, Gloves, Face Mask, and Goggles must be worn beyond this point and entered another resident room that did not have a sign on the door. AA #1 spoke with the resident and stood within 6 feet of the resident, and the resident was not wearing a mask. AA #1 exited the room and entered another resident room with a sign next to the door PPE Gowns, Gloves, Face Mask, and Goggles must be worn beyond this point. AA #1 sat on the resident's bed within 6 feet of the resident and read to the resident. The resident was in a wheelchair next to the bed and was not wearing a mask. Throughout the observation period, AA #1 was wearing a gown and face mask, was without gloves and did not change any portion of the PPE or perform hand hygiene before entering or exiting resident rooms. During an interview on 5/11/20 at 2:50 PM, RA #2 stated that, before entering a resident's room she put on a gown and followed the signs on or next to the resident's door, and she was aware she was entering and exiting COVID positive rooms and COVID negative rooms. She stated she was not sure what she was supposed to do regarding changing PPE because she had been given different instructions over the last couple weeks. She stated there should be more instruction given from the facility to staff about going from COVID positive rooms to COVID negative rooms. During an interview on 5/11/20 at 2:55 PM, AA #1 stated she had not received training on PPE or COVID-19 procedures in the facility. She was not sure if she should wear gloves or if she should change PPE upon entering or exiting COVID positive and COVID negative resident rooms. She stated a nurse on another unit told her she did not have to change PPE when going in and out of resident rooms. She stated she was sitting on the resident's bed that had signage next to the door that PPE was required and that probably was not a good idea. She stated she should probably have had gloves on in resident rooms. During an observation on 5/11/20 RA #4, while delivering meal trays, exited a COVID positive resident's room, then entered a COVID negative resident's room, then entered another COVID positive resident's room, and then entered another COVID negative resident's room, The RA did not perform hand hygiene or change PPE during this observation. During an interview on 5/11/20 Registered Nurse (RN) #1 stated the PPE sign on or near the resident's door was to inform staff that the resident in the room was COVID positive and they needed the PPE listed on the sign to enter the room. RN #1 also stated, any staff exiting a COVID positive room should change PPE and wash hands. UNIT 6 During an observation of Unit 6 on 5/11/20 at 1:14 PM, Certified Nurse Aide (CNA) #1 entered and exited resident rooms with and without signs on or next to the door that stated PPE Gowns, Gloves, Face Mask, and Goggles must be worn beyond this point to pass lunch trays without changing PPE. CNA #1 was wearing a gown, face mask, face shield, and gloves. During an interview on 5/11/20 at 1:05 PM, CNA #1 stated she was told she did not need to change PPE while passing meal trays and could not recall what was taught in the infection control or PPE training. During an interview on 5/11/20 at 1:18 PM, Licensed Practical Nurse (LPN) #1 stated she was not sure what the staff were supposed to do regarding PPE when going from COVID-19 (COVID) positive rooms to COVID negative rooms. She had not worked in the last 5 days, so was not aware if there had been any changes regarding PPE use during that time. She stated she wore the same PPE throughout the shift, unless she did a treatment on a resident, then she changed her PPE. She stated staff wore the same PPE throughout the shift and should probably change their PPE but did not. During an interview on 5/11/20 the facility Administrator stated all staff were provided COVID training that included appropriate use of PPE and when to change. Upon exiting a COVID positive room staff should change their gown, remove gloves and wash their hands. 10 NYCRR 415.19 (b)(1)

Plan of Correction: ApprovedMay 22, 2020

Corrective Action for those residents/ areas affected:
Units 4 and 6 staff were immediately educated on the policy and procedure of PPE usage as follows- hands were to be washed then gloves were to be put on upon entry into the patient room or care area and removed and discarded when leaving the patient room or care area, and a clean isolation gown was to be put on upon entry into the patient room or area and removed and discarded in the dedicated container for waste/ linen before leaving the rooms of COVID-19.
RA#2- was educated on proper PPE use when leaving a room COVID-19 positive- PPE must be changed and discarded in the dedicated container.
AA#1- was educated on proper PPE -gloves to be worn and to perform hand hygiene before entering or exiting resident rooms. Educated on PPE, PPE needs to be removed and discarded in the dedicated container when leaving the residents room.
RA# 4 ? Educated on performing hand hygiene when entering and leaving residents rooms and changing PPE when going in and out of resident?s rooms during the delivery of meal trays.
CNA#1 was educated on PPE protocol and policy when passing meal trays PPE needs to be changed when going in and out of each resident?s room.
LPN#1- was educated on PPE protocol and policy ? changing PPE when going in and out of resident?s rooms.
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 staff members from each department on the use of PPE and hand-washing. 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. 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.
Systemic Measures to prevent re-occurrence:
Review Policy and procedure on infection control PPE usage by all employees.
In-service All staff on the proper usage of PPE- each staff member needs to show (how-to put-on) PPE and when to take off and change PPE, each staff member will get checked off on proper usage of PPE.
Audit tool created so Nursing Supervisor will check that all PPE is used correctly during evening and night shift.
Implement additional audits on Infection control which will focus on hand washing, each nurse manager will be responsible for auditing staff on PPE usage and infection control compliance on their unit during their scheduled time.
Infection Control nurse will monitor all units on proper 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 by infection control nurse.
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.
Responsible person: Director of Nursing

REPORTING-RESIDENTS,REPRESENTATIVES&FAMILIES

REGULATION: §483.80(g) COVID-19 reporting. The facility must? §483.80(g)(3) Inform residents, their representatives, and families of those residing in facilities by 5 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. This information must? (i) Not include personally identifiable information; (ii) Include information on mitigating actions implemented to prevent or reduce the risk of transmission, including if normal operations of the facility will be altered; and (iii) Include any cumulative updates for residents, their representatives, and families at least weekly or by 5 p.m. the next calendar day following the subsequent occurrence of either: each time a confirmed infection of COVID-19 is identified, or whenever three or more residents or staff with new onset of respiratory symptoms occur within 72 hours of each other.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 13, 2020
Corrected date: June 26, 2020

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the COVID-19 Infection Control Focus Survey completed on 5/11/20, the facility did not inform residents by 5:00 PM the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. Specifically, for 2 (Resident #s 5 and 6) of 2 residents interviewed, the facility did not provide verbal or written notification when a resident at the facility tested positive for COVID-19 or a resident suffered a COVID-19 related death. This is evidenced by: Resident #5: Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool) dated 3/28/20 documented the resident was cognitively intact. During an interview on 5/11/20 at 3:05 PM, Resident #5 stated he/she knew there were COVID positive residents on the unit because he/she saw the PPE signs that hung on or next to those resident's bedroom doors. He/She had never received written or verbal notification from the facility about COVID positive cases or COVID related deaths in the facility. Resident #6: Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident was cognitively intact. During an interview on 5/11/20 at 2:15 PM, Resident #6 stated he/she noticed yellow signs were placed on a resident's room, and that is how he/she was made aware of a newly diagnosed COVID-19 positive resident. Resident #6 stated he/she was his/her own representative and did not have a family member that would be made aware of newly diagnosed residents or deaths from COVID-19 at the facility. He/She had never received written or verbal notification from the facility about COVID positive cases or COVID related deaths in the facility. During an interview on 5/11/20 at 6:22 PM, the Administrator stated residents with cognitive capacity were informed by nursing when a resident is diagnosed with [REDACTED]. The facility had no formal record or tracking system in place for resident/family notification of COVID-19 information, but family or next of kin were notified daily by robocall. Additionally, a letter was sent using a mailing list to the resident directly or their representative if the resident was not their own representative. 10 NYCRR 483.70(b)

Plan of Correction: ApprovedMay 22, 2020

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Action for those residents/ areas affected:
Resident #5: was immediately talked to by Social Work regarding COVID-19 positive cases in the facility. Information on COVID-19 was given to resident for further information regarding [MEDICAL CONDITION].
Resident # 6 was immediately talked to by Social Work regarding COVID-19 positive case in the facility. Information on COVID-19 was given to resident for further information regarding [MEDICAL CONDITION].
Corrective Action taken for other residents with the potential to be affected:
All residents have the potential to be affected. Social work will continue to notify all residents and family members if applicable of the COVID-19 positive cases in the facility. Residents and family members will be offered information on COVID-19 testing and updated information on [MEDICAL CONDITION] when applicable.
Systemic Measures to prevent reoccurrence:
Review Policy and procedure on informing residents and families of COVID-19 cases in the facility.
Social Work to implement a tracking sheet of all residents and residents? families that have been informed on the COVID-19 CASES in the facility. Tracking sheet will be updated daily and will be added to the morning report meeting.
Quality Assurance Monitoring:
Tracking audit for all residents and residents? families will be audited weekly times 4 weeks by Social Work then monthly x6 months until compliant
The tracking audit will be reviewed by the QA committee monthly x 6 months, then as directed by the committee
Responsible person: Director of SW