Every finding on record at Whittier Bradford Transitional Care Unit

Based on observation, record review and interview the facility failed to implement infection control interventions to prevent the spread of infection including Covid-19 when the facility failed to actively screen staff/visitors for Covid-19, staff failed to don (put on) Personal Protection Equipment (PPE) properly and perform hand hygiene on the Transitional Care Unit (TCU). Findings include: Review of the facility's policy titled Covid-19 Control Plan, dated as revised 12/9/2020, indicated: It is the policy of the this facility to utilize administrative, engineering, patient and personal protection mechanisms for the control of Covid-19, based upon recommendations by the CDC (Center for Disease Control, CMS (Centers for Medicare and Medicaid Services) and Massachusetts Department of Public Health. Purpose: To develop and implement a comprehensive program to screen, identify and treat residents/patients, visitors and employees suspected to have or infected with Covid-19, and to establish control measures to prevent the transmission of Covid-19. Procedure: 4. Staff: B. All facility personnel will be screened prior to the start of their shift for elevated temperature and Covid-19 symptoms or exposure. C. Any employee who fails the screen will be sent home. E. All facility personnel will practice frequent hand hygiene. 5. An approved visitor MUST complete a mandatory screening process before being allowed admission into the facility. 6. Vendors a. The vendor representative must enter the main entrance of the building and complete a mandatory screening process with a facility employee. Review of Department of Public Health Guidance dated 12/7/2020, and titled; Update to caring for Long Term Care residents during Covid-19 emergency, indicated: Long-term care facility personnel must be screened for symptoms at the beginning of every shift. Screening of All Individuals; Long-term care facilities should be screening all individuals entering the facility, including healthcare personnel and visitors, for symptoms on a daily basis. In accordance with previously issued guidance, every individual regardless of reason for entering a long-term care facility should be asked about COVID-19 symptoms and must also have their temperature checked by a trained screener. 1. On 12/30/2020 at 7:19 A.M., the surveyors entered the building through the employee entrance. A staff member, who also entered said she worked in the rehabilitation hospital and not the Transitional Care Unit (TCU). When asked about screening, she pointed to a table that had a sign that indicated All TCU employees please fill out this form before going to the floor. The surveyors observed a form on the table labeled Screening tool. The surveyor observed that a thermometer was not on or near the table and was located at the rehabilitation hospital screening area. The surveyor observed that no attendant was present to ensure staff were actively screened for signs and symptoms of Covid-19. At no time after the surveyors entered the TCU did facility staff actively screen the surveyors per the facility policy to ensure the surveyor passed the screening process for entry onto the TCU. During an interview on 12/30/2020, at 12:29 P.M., CNA #1 said she fills out a screening tool, takes her temperature and leaves the form on the table before her shift. She said this is done without a staff member present. During an interview on 12/30/2020, at 12:45 P.M., the Administrator said a staff member should be present to screen staff prior to starting their shift. 2. During an interview on 12/30/2020, at 7:22 A.M., Unit Manager #1 (UM#1) said the unit currently had 5 residents positive for Covid-19 and 3 residents who recently recovered from Covid-19 for a total census of 8 residents. Review of the CDC guidance for the Donning of PPE dated August 19, 2020 indicated: How to Put On (Don) PPE Gear More than one donning method may be acceptable. Training and practice using your healthcare facility's procedure is critical. Below is one example of donning. *Identify and gather the proper PPE to don. Ensure choice of gown size is correct (based on training). *Perform hand hygiene using hand sanitizer. *Put on isolation gown. Tie all of the ties on the gown. Assistance may be needed by other healthcare personnel. *Put on NIOSH-approved N95 filtering facepiece respirator or higher (use a facemask if a respirator is not available). If the respirator has a nosepiece, it should be fitted to the nose with both hands, not bent or tented. Do not pinch the nosepiece with one hand. Respirator/facemask should be extended under chin. Both your mouth and nose should be protected. Do not wear respirator/facemask under your chin or store in scrubs pocket between patients. * *Respirator: Respirator straps should be placed on crown of head (top strap) and base of neck (bottom strap). Perform a user seal check each time you put on the respirator. *Facemask: Mask ties should be secured on crown of head (top tie) and base of neck (bottom tie). If mask has loops, hook them appropriately around your ears. *Put on face shield or goggles. When wearing an N95 respirator or half facepiece [MEDICATION NAME] respirator, select the proper eye protection to ensure that the respirator does not interfere with the correct positioning of the eye protection, and the eye protection does not affect the fit or seal of the respirator. Face shields provide full face coverage. Goggles also provide excellent protection for eyes, but fogging is common. *Put on gloves. Gloves should cover the cuff (wrist) of gown. *Healthcare personnel may now enter patient room. On 12/30/2020, the surveyor made the following observations on the Transitional Care Unit: - At 9:46 A.M., an Environmental Staff member donned a gown outside of a resident room by placing the gown over his head. While doing so, the gown came in contact with his face shield, potentially contaminating the PPE. This resident room was identified as unoccupied by facility census. - At 9:50 A.M., a Housekeeper with gloves on both hands reached for a plastic bag on a cart, using the same gloved hands touched the rim of a trash barrel, and then donned a gown over her contaminated gloves, in turn contaminating the gown. -At 9:52 A.M., the Environmental staff member exited the unoccupied resident room, removed gloves from both hands, tossed them in the trash and without performing hand hygiene, picked up a ladder and walked down the hall. During an interview on 12/30/2020, at approximately 12:45 P.M., the surveyor discussed the observations made with the Administrator and Unit Manager (UM) #1. UM #1 acknowledged that PPE needs to be put on properly and hand hygiene is required after removal of gloves.

Based on observation and interview the facility failed to ensure that a Dietary Aide (DA) properly removed gloves and performed hand hygiene after contact with the environment of multiple residents, potentially contaminating the environment with pathogens. Findings include: The facility policy titled Transmission Based Precautions, revised 3/12/20, indicated: * Don all Personal Protective Equipment (PPE) upon room entry and properly discard in waste receptacle inside the room before exiting the resident's room to contain pathogens; Wash hands immediately. The facility policy titled Special Droplet/Contact Precautions For Residents with suspected or Confirmed COVID-19, revised 6/17/20, indicated: * Wash or gel hands prior to entering the room. * Don all PPE upon room entry. * Remove and dispose of contaminated PPE into a dedicated waste container prior to exiting the room. On 8/5/20 at 1:10 P.M., the surveyor observed a Dietary Aide (DA) walking down the corridor, wearing a glove on each hand, and carrying a clip board. The DA knocked on the door of room [ROOM NUMBER] with a gloved hand, potentially contaminating the doors surface, and entered the room. At 1:19 P.M., the DA exited room [ROOM NUMBER], and without removing the gloves and without performing hand hygiene, proceeded down the corridor to room [ROOM NUMBER]. A sign outside room [ROOM NUMBER] identified that the resident in the room was on Contact precautions until 8/15/20. On 8/5/20 at 1:16 P.M., the surveyor observed the DA knocked on the door of room [ROOM NUMBER] with a gloved hand, again potentially contaminating the surface of the door, and enter the room. At 1:20 P.M., the surveyor observed the DA exit room [ROOM NUMBER], and without removing the gloves and with out performing hand hygiene, she proceeded down the corridor to room [ROOM NUMBER]. A sign outside room [ROOM NUMBER] identified that the resident in the room was on Contact precautions. The DA knocked on the door with a gloved hand, potentially contaminating the surface, and entered the room. On 8/5/20 at 1:21 P.M., the DA exited room [ROOM NUMBER], and without removing the gloves and without performing hand hygiene, proceeded down the corridor to the exit doors. The DA pushed through the exit door, potentially contaminating the surface, and exited the unit with the same gloves in place on both hands. During an interview with the Director of Nursing (DON) on 8/5/20 at 1:55 P.M., she was updated on the observations of the DA and said that she absolutely should not be wearing gloves in the hall, especially room to room, and should be sanitizing her hands as she leaves each room, so yes this is a concern and a problem. During a follow-up conversation with the DON on 8/5/20 at 2:02 P.M., she said that the DA had just returned to the unit wearing a glove on each hand and intervention was provided by herself.

Based on observation, interview and policy review facility staff failed to 1) ensure that medications were locked and inaccessible to residents and 2) ensure that expired medications were not available for administration. Findings include: 1) On 7/9/19 at 4:29 P.M., the surveyor observed the low side medication cart unlocked and unattended in a visibly busy area near the unit's nursing station. The surveyor further observed that the resident medication screen (which contained resident specific health information) was open and visible to staff and other residents walking by. The surveyor further observed an insulin pen (a pen used to inject insulin in the treatment of [REDACTED]. On 7/9/19 at 4:33 P.M., the Director of Nursing walked by and asked the surveyor if the medication cart was unlocked and unattended. She said that Nurse #1 was in a resident room providing care and should not have left the cart unlocked. The Director of Nursing said the medication cart should always be locked when unattended and medication should never be left on the top of the cart. She further said that the resident screen should not be visible. On 7/9/19 at 4:35 P.M., the surveyor interviewed Nurse #1. She said the medication cart should have been locked. She further said that she should have closed out the resident medication screen prior to leaving the medication cart. She said she should not have left the insulin pen on top of the medication cart. Review of facility policy titled Storage of Medications Rev. 2/19/09 indicated the following: -Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. 2) On 7/10/19 at 9:18 A.M., the surveyor observed the medication room on the unit. The following items were available for administration: -House stock intravenous kit (a kit containing intravenous supplies, hydration solutions and flushes and antibiotics for intravenous use) with an expiration date of 6/30/19 -Cubex supply kit (a kit containing intravenous solutions, [MEDICATION NAME] and medications for intravenous use) with an expiration date of 6/30/19 On 7/10/19 at 9:23 A.M., the surveyor interviewed Unit Manager #1. He acknowledged that the items were expired and should have been removed. Review of facility policy titled Storage of Medications Rev. 2/19/09 indicated the following: -Outdated, contaminated, or deteriorated medications and those in containers are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists.

Based on observation, interview and record review the facility staff failed to ensure foods available to residents in the nourishment kitchen were stored in accordance with professional standards for food service safety. During observation on [DATE] at 7:56 A.M., the following was observed in the nourishment kitchen: * 1 case containing 21 (out of a total case of 24), 8 ounce cans of [MEDICATION NAME] Therapeutic Nutrition (a dietary supplement) with an expiration date of [DATE], over 7 months expired. * an open and secured package of cookies not dated. * 5 bottles of opened ginger ale opened and not dated. * 2 bottles of apple juice, opened and not dated * 1 box of fruit juice, opened and not dated. * 1 4 ounce carton of milk, opened and not dated. During an interview on [DATE] at 8:01 A.M., Unit Manager #1 (UM #1) said the nourishment kitchen items are available for use by residents and families. The surveyor asked about the supplement and reviewed the expiration date, UM#1 said he did not know the cans were under the cabinet and that the supplement is provided by the kitchen. ` During an interview on [DATE] at 8:06 A.M., the Food Service Director (FSD) said any food items that are opened are disposed of after 3 to 4 days. The FSD said there would be no way to know when to dispose of an item without the item being dated. He said dietary staff restock and review the refrigerator daily.

Based on observation, record review and interview, the Facility failed to properly assess each resident bed for safety and appropriate fit of the mattresses to reduce the risk of entrapment in 17 out of 17 resident beds in use. During observation of the unit on 8/29/18 and 8/30/18 some of the mattresses appeared to be too short for the bed frame in which the mattress was on, posing a risk of entrapment on the beds observed. On 8/30/18 at 1:00 P.M. the Administrator and a Maintenance staff member performed a room to room assessment of the beds with the survey team. Each bed frame and mattress were assessed. Findings include: room [ROOM NUMBER] beds A and B, room [ROOM NUMBER] bed A, room [ROOM NUMBER] beds A and B, room [ROOM NUMBER] beds A and B, room [ROOM NUMBER] beds A and B, room [ROOM NUMBER] beds A and B, room [ROOM NUMBER] beds A and B and room [ROOM NUMBER] bed A all had a large space between the headboard and the mattress which could pose risk for entrapment. During the assessment with the facility Administrator and Maintenance staff member, it was discovered that the beds with the large spaces between the mattress and the headboard had been adjusted for extended length, but the extended length mattresses and/or bolster cushions designed for this extension were not utilized. Review of the Facility's policy titled, Siderails, guidlines for use of, dated 11/17, indicated that the measuring guidlines are as follows: Maintenance staff are responsible for inspecting facility and resident care equipment including beds, siderails, and mattresses to identify areas of possible entrapment in accordance with FDA guidlines. v. Zone 5 - Between Split Bed Rails. vi. Zone 6 - Between the End of the Rail and the Side Edge of the Head or Foot Board. vii. Zone 7 - Between the Head or Foot Board and the End of the Mattress. Review of the Facility's bed assessments indicated that the facility failed to assess zones 5, 6 and 7 when assessing for risk of resident entrapment. On 8/30/18 at 1:30 P.M., the Facility Administrator and said that he would go bed to bed and fix the entrapment risk immediately as he was unaware of the assessment required for zones 5, 6, and 7.

Based on observation and interview the Facility failed to ensure medications and biologicals that were available for administration were at full potency and effective for the use intended. Findings include: 1. On 8/29/18, at 3:08 P.M., the Surveyor observed the following in the medication room; a. two vials [MEDICATION NAME] open without a date. 2. On 8/29/18, at 3:25 P.M. the Surveyor observed the following in the medication cart; b. 1 bottle of [MEDICATION NAME] (anti-[MEDICAL CONDITION]) eye drops open and without a date. c. 1 bottle of [MEDICATION NAME] (used to treat diabetes) open and without a date. d. 1 bottle of [MEDICATION NAME] (decreases pressure) eye drops open and without a date. e. 1 bottle of Latanoprost (decreases pressure) eye drops open and without a date. f. 1 bottle of [MEDICATION NAME] (anti-[MEDICAL CONDITION]) eye drops open and without a date. g. 1 bottle of Latanoprost eye drops sealed and not in refrigerator. Review of the Facility policy titled storage of Medications and dated revised 2/19/09, indicated medications requiring refrigeration are kept in a refrigerator. Further review indicated outdated . medications are immediately removed from stock and disposed of according to procedure. During an interview on 8/29/18, at 3:25 P.M. Nurse #1 said he was new nurse and was not aware of the need to date eye drops when they are opened. He said he would remove the expired medications and give them to the Director of Nursing to destroy.