The facility did not follow its infection prevention policy by allowing symptomatic staff, including a CNA and a housekeeper, to work while ill, which contributed to a COVID-19 outbreak affecting all residents on a unit. The outbreak resulted in widespread resident infections and required prolonged isolation precautions, as the facility failed to effectively identify and control the spread of infection.
Surveyors found that the facility failed to implement an effective infection surveillance and reporting process during a norovirus gastroenteritis outbreak and in its routine infection tracking. During the outbreak, only a single-day tracking sheet was completed for several residents with gastrointestinal illness on two units, and daily surveillance with updated symptoms and management was not maintained as required by facility policy. Despite receiving a directive from the state health department to submit a Nosocomial Outbreak Reporting Application for the identified cluster, the DON acknowledged that the report was never submitted. Additionally, monthly infection control line lists for residents on antibiotics for various infections lacked documentation of signs and symptoms, diagnostic and lab results, precautions used, and outbreak potential, even though the IP relied on these lists for surveillance.
The facility failed to maintain an effective infection prevention and control program when infection surveillance logs for multiple months were incomplete or missing key information, including organisms, criteria definitions, and tracking of infections. A COVID outbreak and a gastrointestinal illness involving residents and staff were only partially documented with line lists and an email, without investigation summaries to determine etiology or preventive measures. The designated IP had recently assumed the role and was absent and then terminated, and the ADON, who previously served as IP, reported that there were no documents for tracking and trending infections or outbreaks for the prior three months, although antibiotic use was tracked separately.
The facility failed to maintain a comprehensive infection prevention and control program, resulting in inadequate monitoring of antibiotic use, poor infection surveillance during a COVID-19 outbreak, and improper use of disinfectants due to insufficient staff training. Housekeeping staff were unclear about cleaning chemicals and infection control practices, and documentation of infection surveillance and antibiotic stewardship was missing for several months. Leadership changes and lack of staff accountability further contributed to these deficiencies, and key recommendations from health authorities were not documented or acted upon.
Failure to Maintain Infection Control Surveillance and Precautions: The DON described an infection surveillance process based on monthly antibiotic lists rather than real-time symptom tracking, and five residents developed respiratory symptoms without being placed on TBP, monitored consistently, or tested for a possible outbreak. One resident had pneumonia with a wet cough and delayed treatment, another had wheezing and low O2 saturation, and others had ongoing cough or congestion without documented illness monitoring. The facility also failed to implement EBP for a resident with dialysis access devices and a resident with a stage 4 pressure ulcer, despite policy identifying those conditions as requiring EBP.
The facility did not report a COVID-19 outbreak to CDPH L&C as required, despite multiple residents and a CNA testing positive. Additionally, a resident's family member was observed assisting with care in a contact precautions room without wearing PPE, contrary to facility policy. Staff confirmed the visitor had not previously reported any PPE allergies, and the facility's infection control policy required PPE use for all visitors in such situations.
The facility failed to maintain infection surveillance logs for multiple consecutive months and did not document infection locations or types, despite several residents being in isolation for wound infections and multiple residents testing positive for COVID-19. The ADON/Infection Preventionist confirmed the absence of infection tracking logs and surveillance/maps during a COVID-19 outbreak. The DON reported that staff, residents, and families were notified of the first COVID-19 case through various methods but could not provide documentation of these notifications. The facility lacked a specific COVID-19 policy and relied on a COVID-19 QAPI Plan that required staff education and testing of all residents and staff on specified days, but the DON confirmed that required testing intervals were not followed and there was no documented evidence of staff testing, with only a log emailed to the health department reflecting positive resident cases.
The facility failed to implement an effective infection prevention and control program during concurrent outbreaks of influenza, RSV, and COVID-19. Several residents with confirmed respiratory infections, including those with severe cognitive impairment and significant comorbidities, had no physician orders for transmission-based precautions and no care plan interventions addressing their infections. Isolation signage was missing from rooms of infected residents, and visitors entered without performing hand hygiene or using PPE. The IP was absent, and the DON and ADON reported they could not access or interpret the EMR infection tracking system, were not systematically tracking infected or non-infected residents’ respiratory symptoms, and had not entered isolation or droplet precaution orders or related care plans for affected residents. Requested outbreak documentation, including line listings, an outbreak management plan, and ongoing symptom tracking, could not be produced, and EMR infection control records showed the outbreak status and contact tracking had not been updated for several days despite multiple residents and staff reporting respiratory symptoms. These failures resulted in an immediate jeopardy finding under F880 for infection control.
During an influenza outbreak, the facility did not identify the outbreak, failed to initiate droplet precautions, and did not post required signage or notify the local health department. Staff and families were not educated about the outbreak, and the Infection Preventionist and clinical leadership did not verify isolation orders or monitor infection-control compliance. Antiviral medications were not administered as prescribed, and Enhanced Barrier Precautions were not followed during high-contact care activities. These failures led to continued exposure and potential transmission of influenza among all residents.
The facility lacked a site-specific Water Management Plan, with missing risk assessments, system diagrams, and monitoring for Legionella, and staff were unfamiliar with the program. Additionally, an LPN failed to use required PPE during a high-contact activity for a resident on Enhanced Barrier Precautions, and staff interviews revealed uncertainty about PPE requirements.
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