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Based on interview and record review, the facility failed to ensure all policies were reviewed at least biennially. This failure had the potential for the facility staff to follow policies that were not up-to-date standard practices, potentially compromising patient care and health and safety.

Findings:

During a interview and record review on 3/29/21 at 12:40 PM, of the facility policy titled "Influenza and Pneumococcal Vaccine for Adult In-Patient Protocol" dated 11/2006. Licensed Nurse (LN) 1 agreed that was the date on the policy.

During an interview and record review of the above policy on 3/29/21 at 1 PM, Quality and Risk Manager (QRM) agreed the date was 11/2006 but stated she did not believe this was the most current policy. She was asked to provide the most current policy.

During a record review on 3/31/21 at 2 PM, the facility policy titled "Influenza and Pneumococcal Vaccines for the Swing Bed Patient" with a revision date of 1/2017 was reviewed. This policy was noted to only discuss "Pneumococcal Vaccine" with no mention of two different vaccines being available for pneumonia.

During a concurrent phone interview and record review on 4/5/21 at 11:35 AM, QRM agreed that the policy was outdated with the date of 1/2017.

Based on observation, interview and record review, the facility failed to ensure provision of an infection control program, and implement infection control practices in accordance with hospital policy and nationally recognized standards when:

1. Staff did not wear proper Personal Protective Equipment (PPE-protective clothing or equipment, such as gowns, gloves, masks and eye protection, worn to protect from infection) when in Isolation rooms for Covid-19 (a serious respiratory illness spread by droplets released by an infected person) positive patients.

2. Staff did not thoroughly screen patients for the need for pneumococcal vaccines (vaccines that can prevent some cased of pneumonia, a severe infection of the lungs).

This had the potential to result in the transmission of COVID-19 and other communicable diseases to patients, staff and visitors.

Findings:

1. During the initial observation of the facility on 3/29/21 at 11:20 AM with the Director of Nursing (DON), a staff member, later identified as Medical Doctor 1 (MD1) was observed outside of the designated Covid - 19 Red Zone (an area where patients that are confirmed to have Covid-19 are housed) in the ante room (a small enclosed room) where she was putting on PPE. It was noted MD 1 did not put on eye protection and she then entered into the Red Zone and into patient Room 103.

The observation continued and another staff member, Licensed Nurse (LN) 2, went to the doorway of Room 103. LN 3 came out of Room 103 and was not wearing eye protection and went into another room, also with Covid positive patients.

During the same above observation, a concurrent interview with LN 2, confirmed MD 1 was not wearing eye protection in the room. LN 2 was asked if LN 3 had been wearing eye protection and she stated she did not know. LN 2 was asked to observe LN 3 in the room she was currently in which LN 2 did, and LN 2 stated LN 3 was not wearing eye protection. LN 2 agreed all staff should be wearing eye protection in the patient rooms on the Red Zone.

During an interview 3/29/21 at 11:25 AM, DON agreed that all staff should be wearing eye protection while in a Red Zone room.

A review of the facility policy titled, "COVID-19 Infection Prevention and Control" dated, 4/20/2020 read, "Infection Prevention and Control during the COVID-19 and a Pandemic Outbreaks will follow the direction and guidelines of California Department of Health, the Centers for Disease and Control (CDC) and of Cal-OSHA, changing policies as needed."

A review of CDC's recommendation titled "Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 2/23/2021 read, "HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 (COVID-19) infection should adhere to Standard Precautions and use a NIOSH-approved (National Institute for Occupational Safety) N95 or equivalent or higher-level respirator, gown, gloves, and eye protection."

2. A review of the facility policy titled "Influenza and Pneumococcal Vaccine for the Swing Bed Patient" last reviewed 1/2017 read, " ...All Swing Beds Patient regardless of age should receive the Influenza Vaccine annually and the Pneumococcal Vaccine once ..." The policy did not indicate that were are two pneumococcal vaccines available.

A review of CDC recommendation titled "Pneumococcal Vaccine Recommendations" dated 11/21/19 read, "CDC recommends routine administration of pneumococcal polysaccharide vaccine (PPSV23) for all adults 65 years or older. In addition, CDC recommends 13-valent pneumococcal conjugate vaccine (PCV13) based on shared clinical decision-making for adults 65 years or older who do not have an immunocompromising condition, cerebrospinal fluid leak, or cochlear implant and have never received a dose of PCV13."
The recommendation goes on to read, "for adults 65 or older who do not have an immunocompromising condition, cerebrospinal fluid leak, or cochlear implant and want to receive PCV13 and PPSV23, give PCV13 first and a year later give PPSV23."

During a concurrent interview and record review with LN1 on 3/29/21 at 12:20 PM, LN 1 indicated that the Pneumococcal and Influenza screening forms are filled out on admission. The form is scanned to the pharmacy and the pharmacist will review and enter any needed vaccination onto the Medical Administration Record (MAR).

A review of Resident 1's medical record indicated she was admitted to the facility with a diagnosis of "Deconditioning" (diminished ability to perform tasks involved in a person's usual activities of daily living).


During this same interview and record review, Resident 1's screening form for Pneumococcal and Influenza was reviewed. Influenza vaccine was marked as given this season, and pneumococcal vaccination status is unknown. On this form it lists an Inclusion Criteria for the following:
1. Age 65 and above: no history of Pneumococcal vaccine.
2. Age 65 and above but received pneumococcal vaccine more than 5 years ago and the first does being given before age 65.
3. Age 18-64 with chronic medical conditions (see below)
4. Vaccination status unknown.

On Resident 1's vaccination form, the box "Vaccination status unknown" was checked. The box titled "Exclusion Criteria Identified -DO NOT ADMINISTER Screening process complete" was checked. At the bottom of the form was a handwritten "Refused" but the "patient refuses" box was not marked. On Resident 1's form it did not differentiate which Pneumococcal vaccine was or was not given.

A review of Resident's 3 medical record indicated she was admitted to the facility with a diagnosis of "Deconditioning."

During this same interview and record review with LN 1, Resident 3's screening form was reviewed. Resident 3 had a different form than Resident 1. Resident 3's form lists an Inclusion Criteria for the following:
1. Age 65 and above; no history of Pneumococcal vaccine.
2. Age 65 and above received pneumococcal vaccine
a. Vaccine type Unknown.
b. 13-valent pneumococcal conjugate.
c. 23-valent pneumococcal polysaccharide
Date vaccinated -
3. Age 18-64 with chronic medical conditions (see below)
4. Vaccination status unknown.

A concurrent interview and record review on 3/29/21 at 12:40 PM with LN 1. Resident 3 had the "Vaccination status unknown" box checked and the "Inclusion Criteria Met and to Consult Pharmacist" box checked. The bottom of the form had a handwritten note "3/15/21 previously received" and initials. LN1 stated that was a pharmacist note.

During the same interview and record review, LN1 reviewed Resident 3's Electronic Medical Record (EMR) and noted a vaccination history that indicated PCV13 was given 10/29/15 and there was no indication that PPSV23 had been given.

During the same interview, LN1 stated that the vaccination form should be the same for all patients and agreed the form should indicate both forms of pneumococcal vaccines.

A review of Resident 2's medical record indicated she was admitted to the facility with a diagnosis of "Deconditioning".

During the same interview and record review, LN1 was asked to review Resident 2's screening form. A screening form could not be found. LN1 stated every patient should have a form done on admission.

During a concurrent interview and record review of the above vaccination screening forms on 3/29/21 at 1:00PM with QA, she agreed the forms should be the same.