A Holly Patterson Extended Care Facility
January 24, 2022 Covid19 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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 24, 2022
Corrected date: February 28, 2022

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during a COVID-19 Focused Infection Control Survey (FICS) completed on 1/24/2022, the facility failed to 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 COVID-19 infection. Specifically, the facility did not ensure the door to resident rooms were closed if the resident tested positive for COVID-19 infection. Resident #1's door was observed open however, had signage indicating to keep the room door closed. The finding is: The Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations to Prevent [DIAGNOSES REDACTED]-CoV-2 Spread in Nursing Home dated (MONTH) 29, 2021, documented that it is recommended that the door to the (resident) room remain closed to reduce transmission of [DIAGNOSES REDACTED]-CoV-2. This is especially important for resident with suspected or confirmed [DIAGNOSES REDACTED]-Cov-2 infection being cared for outside of the COVID-19 care unit. The facility's policy titled COVID-19 Surveillance, Monitoring and Management dated 3/16/2020 and last revised on 12/2021 documented under management, page 3 of 3, units are closed, and corridor doors remain closed. During the entrance conference on 1/21/2022 at 9:30 AM, the Director of Nursing Services (DNS) stated that COVID-19 positive residents are scattered throughout the building and are kept in their rooms. All units within the facility are currently on Transmission-Based Precautions. Resident # 1 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 8 which indicated the resident had moderately impaired cognition. The resident was non-ambulatory. The physician's orders [REDACTED].#1 was to be placed on contact and droplet precautions. A Polymerase Chain Reaction (PCR) laboratory test results dated 1/11/2022 documented Resident #1 was positive for COVID-19 infection. On 1/21/2022 at 12:05 PM, during tour of Unit 22, Resident # 1's Room door had a sign that indicated the resident was on Droplet/Contact Precautions. The sign read to keep door closed. Resident #1 was observed in their room with their room door partially open. The Registered Nurse (RN) # 9 was interviewed on 1/21/2022 at 12:10 PM and stated the resident room doors should be closed and could not explain why Resident #1's room door was left open. RN #9 did not know who had left Resident #1's room door open. The Infection Control RN# 2 and the Director of Nursing Services (DNS) were interviewed concurrently on 1/21/2022 at 1:10 PM and stated Resident #1 was still on Droplet and Contact Precautions on 1/21/2022 and the room door should have been closed shut. 415.19 (a) (1-3)

Plan of Correction: ApprovedFebruary 17, 2022

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Holly Patterson Extended Care Facility, AHPECF as directed by the DOH has obtained the services of a consultant, not employed by the facility, to develop and implement plan of correction. AHPECF has reached out to DOH Nursing Home Surveyor Program Manager and submitted names, contact information, Bio, CV, and company information as requested. DOH has agreed AHPECF can move forward with this consultant group. AHPECF has identified and completed a root cause analysis. After the root cause analysis it was determined that the door sign was not updated to reflect current CDC-DOH guidelines titled - Interim Infection Prevention and Control Recommendations to Prevent [DIAGNOSES REDACTED]-CoV-2 Spread in Nursing Homes, which states Keeping the door closed may pose resident safety risks and the door might need to remain open. This is the case of resident #1 on ventilator unit 22. The resident is non-ambulatory, however, due to his [MEDICAL CONDITION] [DIAGNOSES REDACTED]. Staff will update care plan on affected resident indicating why/reasons door needs to remain open. The AHPECF acknowledged that it must establish and maintain infection control measures in accordance with the CDC DOH COVID-19 guidelines, along with implementing and executing established facility policies to prevent spread of infection and transmission of communicable diseases. Resident#1 room door was not closed per previous CDC-DOH recommendations for Long Term Care and facility policy. Staff on unit#22 was in-serviced on the importance of following facility's policy to keep doors closed for residents on COVID precautions to prevent the spread of [DIAGNOSES REDACTED] COVID-19. The above mentioned resident's door signage was immediately changed to reflect CDC-DOH recommendations. The doors to residents on COVID precautions were checked and found to be closed and in compliance with the CDC-DOH recommendations and facility policy on Surveillance Monitoring, and Management of [DIAGNOSES REDACTED] COVID-19. Facility staff has been in-serviced on following facility policy to ensure doors of residents with suspected or confirmed [DIAGNOSES REDACTED] COVID-19 remain closed to reduce transmission of the infection, if able, except when closing the door poses a safety risk. Facility policy on COVID-19 Surveillance, Monitoring and Management, signage and policy updated to follow CDC-DOH guidelines. 1. Sign on door was updated to follow current LTC DOH-CDC recommendations 2. PPE continue to be required for entering the room of a COVID-19 positive resident. 3. Removing PPE before leaving the room continues as per policy 4. Staff will continue to wash hands AHPECF will do random weekly rounds conducted by Infection Preventionist (IP) and/or Designee to ensure infection control measures are followed. These random audits will also serve to show the successful efforts of facility compliance. Nurse Manager (NM) will communicate to IP/Designee findings needing immediate corrective actions. IP will work with Quality Assurance (QA) and submit data on findings on a monthly and quarterly basis for the next 3 quarters. QA and IP will determine if further recommendations are needed to maintain compliance. Consultants and AHPECF completed assessment of the causative factors as mentioned above which contributed to issue causing deficiency. Specific steps and interventions as also mentioned above were immediately taken to eliminate this from occurring again. The facility has set up random audits to check that door signs are in place. The facility has changed door signage to reflect current CDC-DOH long term care guidelines as mentioned above. The corrective actions were immediately accomplished for resident #1 and those potential residents who will be affected. The facility will continue to monitor and implement all updated CDC-DOH COVID-19 guidelines. The date of correction will be completed 2/28/22. The persons responsible for corrective action is IP.