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Due to the degree of the deficient practice, the facility failed to meet the Condition of Participation for Infection Prevention specific to COVID-19 Infection Control for Acute and Continuing Care.

Based on observation, interview, and record review:

The facility staff failed to ensure they employed an Infection Prevention and Control Specialist who was appointed by the Governing Body, and based upon the recommendations of the Medical Staff (See C1204); failed to establish a facility-wide IPCP including written standards, policies, and procedures that were current and based on national standards for undiagnosed respiratory illness and COVID-19 (See C1206); and failed to ensure all staff, including contracted agency and volunteer staff, were trained on the facility's Infection Control policies and procedures, specific to hand hygiene and PPE use, during care for those patients suspected or known to have COVID-19 (See C1208).

Based on interview and record review, facility staff failed to ensure failed to ensure the individual employed as the Infection Prevention and Control Specialist was appointed by the facility's Governing Body based on the recommendations by the Medical Staff. These deficient practices directly contributed to the spread of the COVID-19 infection within its facility which affected 20 (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 17, 18, 19, 20, and 21) of 22 sampled patients. Findings include:

During an interview on 10/14/20 at 9:40 a.m., staff member A stated staff member BB was the current Infection Prevention and Control Specialist, but staff member BB had not completed the required certifications. Staff member A stated facility staff were following current CDC guidelines, but no policies had been updated to reflect COVID-19. Staff member A stated the Governing Body had met earlier in the year, but the Infection Prevention and Control Specialist position and duties had not been discussed, during that meeting.

During an interview and record review on 10/14/20 at 1:30 p.m., a request for the current CDC guidelines and recommendations the facility staff were following was made. Staff member A stated she would need to log into the CDC website and print off copies. She stated the facility did not have any policies available, specific to COVID-19, and according to CDC guidelines.

A review of a facility document, LTC Covid [sic] Testing, printed 10/15/20, showed patients' #s 1 through 14, and 16 through 21, had tested positive for COVID-19 from 9/21/20 through 9/28/20.

A review of CDC guidelines, provided by the facility, included:
- The National Institute for Occupational Safety and Health (NIOSH), updated 3/27/20, "Recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Facepiece Respirators in Healthcare Settings."
- Coronavirus Disease 2019, updated 7/15/20, "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic."
- Coronavirus Disease 2019, updated 7/17/20, "Strategies to Mitigate Healthcare Personnel Staffing Shortages."

Based on interview and record review, facility staff failed to ensure a facility-wide IPCP, with written policies and procedures, based on national standards for undiagnosed respiratory illness and COVID-19, had been developed. This deficient practice directly contributed to the spread of the COVID-19 infection within its facility which affected 20 (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 17, 18, 19, 20, and 21) of 22 sampled patients. Findings include:

During an interview on 10/14/20 at 9:40 a.m., staff member A stated the facility had not developed written policies and procedures, specific for the prevention of respiratory illnesses and COVID-19, recommended by CMS Guidelines. Staff member A stated staff member BB was the current Infection Prevention and Control Specialist, but staff member BB had not completed the required certifications. Staff member A stated facility staff were following current CDC guidelines.

During an interview and record review on 10/14/20 at 1:30 p.m., a request for the current CDC guidelines and recommendations the facility staff were following was made. Staff member A stated she would need to log into the CDC website and print off copies. She stated the facility did not have any policies available, specific to COVID-19, in accordance to CDC guidelines and CMS recommendations.

A review of a facility document, Employee COVID19 [sic], printed on 10/14/20, showed staff members B, D, H, I, J, K, L, M, N, O, P, Q, S, T, U, V, W, X, Y, Z, AA, BB, and CC had tested positive for COVID-19 from 8/12/20 through 10/5/20. No staff had tested positive since 10/5/20.

A review of a facility document, LTC Covid [sic] Testing, printed 10/15/20, showed patients' #s 1 through 14, and 16 through 21, had tested positive for COVID-19 from 9/21/20 through 9/28/20.

A review of CDC guidelines, provided by the facility, included:
- The National Institute for Occupational Safety and Health (NIOSH), updated 3/27/20, "Recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Facepiece Respirators in Healthcare Settings."
- Coronavirus Disease 2019, updated 7/15/20, "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic."
- Coronavirus Disease 2019, updated 7/17/20, "Strategies to Mitigate Healthcare Personnel Staffing Shortages."

Based on observation, interview, and record review, the facility failed to ensure all staff, including contracted agency and volunteer staff, were trained on the facility's Infection Control policies and procedures, specific to hand hygiene and PPE use, the storage and handling of PPE between patient use, the donning and doffing PPE after exiting and entering patient rooms, especially during care for those patients suspected or known to have COVID-19 for 6 (#s 1, 5, 10, 16, 17, and 22) of 22 sampled patients. Findings include:

1. During an observation on 10/14/20 at 9:10 a.m., a yellow isolation gown was seen hanging from a hook in the 200 hallway, between the double doors and room 202. The sign taped above the gown said, "[name] dirty gown." The gown was hanging with the contaminated side facing away from the wall. There was an N95 mask hanging from the hook with the staff side (clean) touching the contaminated side of the isolation gown.

During an interview on 10/14/20 at 4:10 p.m., staff member C stated all gowns hanging were to be disposed of at the end of each shift and were not used for more than one day.

During an interview on 10/14/20 at 7:30 p.m., staff member U stated none of the gowns hanging on hooks in the hallway were from her shift, and they were left over from the day shift. Staff member U stated she usually had to throw them away when she comes on shift.

During an observation on 10/14/20 at 7:52 p.m., multiple isolation gowns were seen hanging from hooks on the 200 hallway, leftover from the day shift.

2. During an observation and interview on 10/14/20 at 9:20 a.m., staff members D and FF entered patient #22's room wearing clean gowns and gloves, and surgical masks which had been worn since the beginning of their shift. Staff member D stated patient #22 was one of three patients who had not tested positive for COVID-19. After assisting patient #22, staff members D and FF exited the room. Staff member D removed her gown and gloves at the same time, disposed of the gloves, and took the gown to a storage room where she hung it up and then performed hand hygiene with ABHS.

3. During an observation and interview on 10/14/20 at 9:25 a.m., staff member E exited patient #10's room. Signage on patient #10's door showed isolation precautions were in place. Staff member E stated patient #10 was positive for COVID-19, and she was supposed to wear a gown, gloves, and a surgical mask. Staff member E removed her gown with bare hands and took the gown to a location down the hall where she hung up the gown.

4. During an observation and interview on 10/14/20 at 9:32 a.m., patient #16 was in her room with no signage on the door reflecting which isolation precautions were necessary. NF2 stated patient #16 had moved to the room a few days ago, and that may be why there was no signage on her door.

5. During an observation on 10/14/20 at 9:59 a.m., NF2 entered patient #10's room. NF2 wore a gown, gloves, and a mask. NF2 wheeled a vital sign (VS) cart into patient #10's room. After NF2 greeted patient #10, NF2 placed a clipboard on the patient's nightstand table next to the bed. After NF2 obtained a set of vital signs (blood pressure, temperature, pulse oximetry for oxygen saturation levels, and pulse) NF2 exited patient #10's room. NF2 did not change his gloves, nor did he use any Alcohol-Based Hand Sanitizer (ABHS) after exiting the patient's room, and before entering the next patient's room.

Patient #10 was admitted with diagnoses including fever, SARS-CoV-2, sore throat, nausea, cough, and headache. Review of a SARS-CoV-2 RNA laboratory test, dated 9/24/20 at 11:33 a.m., showed patient #10 tested positive for COVID-19 on 9/24/20 at 5:19 p.m.

6. During an observation on 10/14/20 at 10:04 a.m., NF2 entered patient #16's room. NF2 wore a gown, gloves, and a mask. NF2 wheeled a VS cart into patient #16's room. After NF2 greeted patient #16, NF2 placed a clipboard on the patient's nightstand table next to the bed. After a set of vital signs was obtained, NF2 exited patient #16's room, without performing hand hygiene, and before entering the next patient's room.

Patient #16 was admitted with diagnoses including fever, decrease in appetite, suspected COVID-19, and fatigue. Review of a SARS-CoV-2 RNA laboratory test, dated 9/24/20 at 2:28 p.m., showed patient #16 tested positive for COVID-19 on 9/24/20 at 5:19 p.m.

7. During an observation on 10/14/20 at 10:07 a.m., NF2 entered patient #17's room. NF2 wore a gown, gloves, and a mask. NF2 wheeled a VS cart into patient #17's room. NF2 entered patient #17's room, but housekeeping staff was mopping the floor, so NF2 exited. NF2 informed patient #17 he would return to obtain a set of vital signs when the floor was dry. NF2 exited patient #17's room, without performing hand hygiene, and before entering the next patient's room.

Patient #17 was admitted with diagnoses including suspected COVID-19. Review of a SARS-CoV-2 RNA laboratory test, dated 9/24/20 at 2:11 p.m., showed patient #17 tested positive for COVID-19 on 9/24/20 at 10:25 p.m.

8. During an observation on 10/14/20 at 10:10 a.m., staff member D exited patient #1's room. Staff member D doffed a gown and pair of gloves. Staff member D hung the gown on a hook, in the hallway, outside of room #101. Staff member D walked to the nurse's station. Staff member D did not wash her hands with soap and water, or use an ABHS after exiting patient #1's room. The patient was currently being quarantined.

During an observation on 10/14/20 at 10:12 a.m., NF2 entered patient #1's room; the patient was currently being quarantined. NF2 wore a gown, gloves, and a mask. NF2 wheeled a VS cart into patient #1's room. After NF2 greeted patient #1, NF2 placed a clipboard on the patient's nightstand table next to the bed. After a set of vital signs was obtained, NF2 exited patient #1's room, without performing hand hygiene, and before entering the next patient's room.

Patient #1 was admitted with diagnoses including lethargy, fever, and suspected COVID-19. Review of a SARS-CoV-2 RNA laboratory test, dated 9/24/20 at 2:05 p.m., showed patient #1 tested positive for COVID-19 on 9/24/20 at 3:32 p.m.

9. During an observation on 10/14/20 at 10:13 a.m., NF2 entered patient #5's room. NF2 wore a gown, gloves, and a mask. NF2 wheeled a VS cart into patient #5's room. After NF2 greeted patient #5, NF2 placed a clipboard on the patient's nightstand table next to the bed. After a set of vital signs was obtained, NF2 exited patient #5's room, without performing hand hygiene. At 10:15 a.m., NF2 returned the VS cart to the Nurse's Station and walked to the Conference Room where he was currently assigned to work from. NF2 discarded his PPE in a regular trash can outside of the conference room. The patient was currently being quarantined.

Patient #5 was admitted with diagnoses including fever and SARS-CoV-2. Review of a SARS-CoV-2 RNA laboratory test, dated 9/24/20 at 2:43 p.m., showed patient #5 tested positive for COVID-19 on 9/24/20 at 4:46 p.m.

During an interview on 10/14/20 at 10:20 a.m., NF1 and NF2 stated they had not been instructed by the facility to wash their hands or use an ABHS after direct contact with patients being quarantined for suspected/active COVID-19. NF1 stated he and NF2 had been instructed to discard PPE (gowns, gloves, and masks) in the "Hazardous Room" near the Nurse's Station. NF2 stated he should have discarded his PPE in the Hazardous Room near the Nurse's Station.

During an interview on 10/14/20 at 12:36 p.m., staff member Y stated she had provided orientation to NF1 and NF2 on their first day at the facility. Staff member Y stated orientation included hand hygiene and the donning and doffing of PPE. Staff member Y stated she did not know by whom hand hygiene and PPE auditing was to be completed.

A review of a facility document, "Approved [name] Duties," read, "...Donning, doffing PPE, follow isolation precautions (OJT, if needed) ... "

A review of a facility document, "Orientation," read, "... Handwashing, N95 fit testing, Donning and Doffing, Bio-hazard room, Hallway PPE carts and doffing carts, UV-C light sterilization procedure..."

Review of the facility policy, Isolation Precautions, revised 5/26/20, read, "STANDARD PRECAUTIONS A. Hand washing...Wash hands immediately after gloves are removed, between patient contacts and when otherwise indicated to avoid transfer of microorganisms to other patients or environments...B. Gloves: ... Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of micro-organisms. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces and before going to another patient..."