Senior Abuse Law

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of infection documentation, observations and interviews, the facility failed to maintain an Infection Control Program, for 3 of 3 sampled Residents ( #3, #6, and #18) from a total sample of 18 Residents, designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.

Findings include:

A. The facility failed to implement timely precautions according to theInfection Control Program policy and procedures to prevent the spread of infections for 1 Resident (#6). B. For 2 residents (#3 and #18 ) the facility failed to maintain complete surveillance data including active infections and use of precautions to track organisms that are infectious or viral for an effective infection control program to ensure a safe environment to help prevent the exposure or transmission of infections.

A. 1. For Resident #6, the facility failed to follow their own policy for implementing contact precautions. Resident #6 was admitted to the facility in 9/2016, with [DIAGNOSES REDACTED]. On 9/28/16 at 9:00 A.M., during tour of the first floor unit with the Unit Manager (UM #1), the surveyor observed that Resident #6 did not have a precaution set-up outside his/her room, and a precaution sign was not posted on Resident #6’s door. The surveyor interviewed UM #1 at 9:30 A.M. on 9/28/16. The UM #1 said she usually checks precaution set-ups first thing in the morning, but did not that morning. The surveyor asked UM #1 who was responsible for setting up precautions when a Resident is admitted with an infection that requires precautions. The UM #1 said the nurse who admitted the Resident was responsible for setting up the precautions and posting the sign. The UM #1 said the precaution set-up carts were kept in the utility room. The facility Infection Control Policy indicated that the nurse caring for the Resident at the time precautions are initiated is responsible to place the precaution sign on the Resident’s room door. The facility failed to implement the infection control program according to policy and procedure guiudelines to prevent the spread of infection.

B.During an interview with the Infection Control Coordinator (ICC) on 9/29/16 at 3:00 P.M., a current listing of residents requiring precautions for infection control purposes was requested for review. The ICC presented a listing of residents that had been on precautions for the year 2016, to date (1/2016 to 9/29/16). According to the ICC, she said that the Unit Nurse Managers complete a line listing from each resident unit including resident name, room number, category of infection, date of onset, symptom, culture date, site, results (organism), treatment, infection cleared, and acquired status of infection (in house or community) and she attends morning meeting and tracks the infection data.

B1. Record review for Resident #3 indicated that Resident #3 was treated for [REDACTED]. Resident #3 was admitted with [DIAGNOSES REDACTED]. Review of the Minimum Data Set assessment completed on 8/4/16, indicated that Resident #3 had indicators of inattention and disorganized thinking, and was dependent for all activities of daily living. Medical record review and nursing notes dated 9/15/16, indicated Resident #3 was identified with a rash on the side of his/her neck. The resident was evaluated by the physician on 9/15/16. The medical progress note indicated the Resident’s neck area had a red maculopapular rash area that was very concerning for [MEDICATION NAME] ([MEDICATION NAME]-Herpes [MEDICATION NAME] virus) and a new order for an antiviral medication ([MEDICATION NAME]) was prescribed, 500 milligrams once a day for 7 days. Survey team had requested to discuss and review the infection control program on 9/28/16 with the ICC and to provide current surveillance / line listing data of the facility’s resident units and to identify residents on precautions. According to the ICC, the unit nurse managers complete a line listing from each resident unit which include: resident name, room number, category of infection, date of onset, symptom, culture date, site, results (organism), treatment, infection cleared, and acquired status of infection (in house or community). The ICC said that she tracks who is on precautions and receives information from morning meetings of any new infections and reports of any prescribed antibiotics.

Review of the facility’s 9/2016 line listing of residents on infection control precautions provided on the afternoon of 9/29/16 failed to indicate that Resident #3 had been on (infection control) precautions. During further interview, the ICC said that she would provide further clarification and provided a listing of all residents on precautions for the entire year (2016) to current date (9/30/16). Review of that listing also failed to indicated that Resident #3 had been on any precautions during the month of 9/2016. Follow up on 10/4/16 with the ICC, she said that it must have been on another page and proceeded to provided a third listing of residents on precautions during 9/2016 to 10/2016. At that time it was noted that Resident #3 was added to the facility’s infection control surveillance for precautions. Although the monthly 9/2016 line listing provided on 10/4/16 at 5:00 P.M. indicated Resident #3 was prescribed an antiviral medication, the infection control surveillance data collection information was not complete in order to track and assist in preventing the spread of infections.

B2. Record review for Resident #18 indicated that Resident #18 was treated for [REDACTED]. Resident #18 resided at the facility for long term care, with [DIAGNOSES REDACTED]. Review of the Minimum Data Set assessment completed on 8/18/16 indicated this Resident was alert and oriented (BIMS score of 11/15), with some inattention and verbal behavioral indicators. For activities of daily living, this resident required extensive assistance, had advanced directives and an invoked health care proxy. Medical record review and nursing notes dated 6/28/16, indicated Resident #18 had complained of back pain and had received pain medication. The pain continued and the Resident was found with a cluster of red blisters on lower back and increased pain in that area. The resident was evaluated by the physician on 6/28/16. The medical progress note indicated Resident #18 has Herpes [MEDICATION NAME] on lower back area. A treatment for [REDACTED]. Review of the listing provided by the ICC of all residents on precautions for the entire year (2016) to current date (9/30/16), failed to indicated that Resident #18 had been on any precautions during the month of 6/2016 or 7/2016. Review of the facility’s line listing of infections for the months of 6/2016 and 7/2016 failed to identify Resident #18 with any (viral infection) or condition that required infection control monitoring or precautions. The infection control surveillance data collection information was not complete in order to track and assist in preventing the spread of infections. During interview with the Infection Control Coordinator (ICC) on 10/4/16, said that she could not explain why Resident #3 and #18 were not listed on the initial listings provided for the facility’s surveillance data of residents requiring precautions during the year 2016 to present.

Further interview the ICC said that she was also the facility Staff Development Coordinator (SDC), Wound Nurse, and the Quality Assurance Coordinator and had been on vacation the end of June and beginning of July 2016 and that Resident #18’s infection/precautions was not included in the data collection for the facility’s infection control program. The ICC said that she understood that if the surveillance data was incomplete the facility could not accurately analyze the data to plan effective prevention / education program.