Otterbein Sunset House

Based on record review and staff interview, the facility failed to follow physician orders to obtain daily weights to monitor for fluid overload. This affected two (#20 and #1) of three residents reviewed for daily weights. The facility census was 18.

Findings include:

1. Review of the medical record for Resident #20 revealed an admission date of 10/12/23 and a discharge date of 12/18/23. Diagnosis included congestive heart failure (CHF).

Review of the physician orders for Resident #20 revealed an order for daily weight and to notify the physician of a greater than two-pound weight gain in 24 hours, or greater than five pound weight gain in one week.

Review of Resident' #20's Treatment Administration Record (TAR) for 10//23 revealed no daily weights were obtained for the following days: 10/17/23, 10/18/23, 1022/23, 10/24/23, 10/25/23, 10/27/23, 10/28/23, 10/29/23, 10/30/23, and 10/31/23.

Review of the TAR for the month of 11/23 revealed revealed no daily weights were obtained for th following days: 11/02/23, 11/04/23, 11/05/23, 11/08/23, 11/09/23, 11/10/23, 11/12/23, and 11/13/23.

Review of the TAR for the month of 12/23 revealed revealed no daily weights were obtained for th following days: 12/04/23, 12/07/23, 12/08/23, 12/09/23, 12/10/23, 12/11/23, and 12/17/23.

2. Review of the medical record for Resident #1 revealed an admission date of 01/17/19 with a diagnosis of heart failure.

Review of the current physician orders for Resident #1 revealed an order to obtain a daily weight and notify the physician for weight gain of greater than two pounds in 24 hours or greater than five pounds in one week.

Review of the TAR for Resident #1 for 11/23 revealed revealed no daily weights were obtained for the following days: 11/02/23, 11/03/23, 11/05/23, 11/06/23, 11/07/23, 11/08/23, 11/09/23, 11/10/23/11/11/23, 11/12/23, 11/15/23, 11/17/23, 11/20/23, and 11/26/23.

Review of the TAR for Resident #1 for 12/23 revealed revealed no daily weights were obtained for the following days: 12/04/23, 12/09/23, 12/21/23, 12/23/23, 12/24/23, and 12/25/23.

Interview on 01/22/24 at 12:45 P.M. with the Director of Nursing (DON) verified daily weights were missing for Resident #20 and Resident #1.

This deficiency represents non-compliance investigated under Complaint Number OH00149536.

Based on medical record review, staff interview, and drug manufacturer indications for use, the facility failed to ensure medications were obtained and administered as prescribed in a timely fashion. This affected one (#1) of five residents reviewed for the provision of medications. The census was 14.

Findings include:

Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on 01/20/23. Diagnoses included a right humerus fracture, COVID-19, coronary artery disease, carotid artery stenosis, hypertension, hyperlipidemia, malignant neoplasm of bladder, peripheral vascular disease, and cerebral infarction.

Review of the Minimum Data Set (MDS) assessment dated 01/24/23 revealed Resident #1 was assessed with moderately impaired cognition and was dependent on staff for the completion of activities of daily living.

Review of Resident #1's nursing progress notes on 02/16/23 at 8:12 A.M., Resident #1 tested positive for COVID-19. The Director of Nursing was notified and the resident was placed into droplet isolation. At 10:09 A.M., Resident #1's family member was notified of the positive COVID-19 test result. At 10:42 A.M., the physician was notified and no new orders were obtained. Further review of the nursing progress notes on 02/17/23 at 2:24 P.M. revealed Resident #1's family representative requested to call the physician to obtain a monoclonal (antiviral) medication to reduce COVID-19 symptoms and the nurse noted a voicemail was left for the physician. On 02/19/23 at 10:45 P.M., the nurse indicated the medication Paxlovid (150/100) oral tablet therapy pack give 150 milligrams (mg) by mouth every morning and at bedtime every five days was ordered, but the the medication was not in stock and the facility was awaiting arrival from pharmacy. The order was changed for Resident #1 to start the medication in the morning on 02/20/23. Review of a nursing progress note dated 02/20/23 at 7:54 A.M. revealed the nurse documented Resident #1's Paxlovid was not available. A nursing progress note was written on 02/20/23 at 1:47 P.M. that Resident #1's Paxlovid medication was delivered and was given after lunch. There was no further documentation contained in the medical record noted the medication was administered. Review of a a nursing progress note on 02/23/23 at 11:53 A.M. revealed the nurse noted having the Paxlovid in the computer, but it was not on the electronic medication administration record (EMAR) to allow for administration. The nurse communicated the concern with the Director of Nursing and updated the family that the medication was available; however, the medication could not be given until it was transcribed to the EMAR. Resident #1 received the medication during the evening medication administration of 02/23/23.

Review of the February 2023 medication administration record (MAR) revealed Resident #1 did not receive the first dose of Paxlovid 150 milligrams (mg) until the evening of 02/20/23 and another dose was not given until 02/23/23 due to a transcription error.

Interview with the Administrator and Director of Nursing(DON) on 03/03/23 at 11:35 A.M. confirmed Resident #1 did not receive the medication Paxlovid from the pharmacy in a timely manner. The physician was notified of the medication request on 02/17/23 and did not respond until 02/19/23. One dose of the medication was administered during the evening of 02/20/23 and not administered again until 02/23/23 in the evening due to a transcription error. The DON verified the primary pharmacy was unable to obtain the medication and attempted to contact a secondary pharmacy that was unable to obtain the medication. No communication from the pharmacy was provided to the facility until 02/19/23 regarding the status of the medication.

Review of Paxlovid manufacturer indications for use, revised February 2023, instructed to initiate Paxlovid treatment as soon as possible after diagnosis of COVID-19 and within five days of symptom onset.

This deficiency represents non-compliance investigated under Master Complaint Number OH00140774.

Based on medical record review, staff interview, and drug manufacturer indications for use, the facility failed to ensure medications were obtained and administered as prescribed by the physician. This affected one (#1) of five residents reviewed for the provision of medications. The census was 14.

Findings include:

Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on 01/20/23. Diagnoses included a right humerus fracture, COVID-19, coronary artery disease, carotid artery stenosis, hypertension, hyperlipidemia, malignant neoplasm of bladder, peripheral vascular disease, and cerebral infarction.

Review of the Minimum Data Set (MDS) assessment dated 01/24/23 revealed Resident #1 was assessed with moderately impaired cognition and was dependent on staff for the completion of activities of daily living.

Review of Resident #1's nursing progress notes on 02/16/23 at 8:12 A.M., Resident #1 tested positive for COVID-19. The Director of Nursing was notified and the resident was placed into droplet isolation. At 10:09 A.M., Resident #1's family member was notified of the positive COVID-19 test result. At 10:42 A.M., the physician was notified and no new orders were obtained. Further review of the nursing progress notes on 02/17/23 at 2:24 P.M. revealed Resident #1's family representative requested to call the physician to obtain a monoclonal (antiviral) medication to reduce COVID-19 symptoms and the nurse noted a voicemail was left for the physician. On 02/19/23 at 10:45 P.M., the nurse indicated the medication Paxlovid (150/100) oral tablet therapy pack give 150 milligrams (mg) by mouth every morning and at bedtime every five days was ordered, but the the medication was not in stock and the facility was awaiting arrival from pharmacy. The order was changed for Resident #1 to start the medication in the morning on 02/20/23. Review of a nursing progress note dated 02/20/23 at 7:54 A.M. revealed the nurse documented Resident #1's Paxlovid was not available. A nursing progress note was written on 02/20/23 at 1:47 P.M. that Resident #1's Paxlovid medication was delivered and was given after lunch. There was no further documentation contained in the medical record noted the medication was administered. Review of a a nursing progress note on 02/23/23 at 11:53 A.M. revealed the nurse noted having the Paxlovid in the computer, but it was not on the electronic medication administration record (EMAR) to allow for administration. The nurse communicated the concern with the Director of Nursing and updated the family that the medication was available; however, the medication could not be given until it was transcribed to the EMAR. Resident #1 received the medication during the evening medication administration of 02/23/23.

Review of the February 2023 medication administration record (MAR) revealed Resident #1 did not receive the first dose of Paxlovid 150 milligrams (mg) until the evening of 02/20/23 and another dose was not given until 02/23/23 due to a transcription error.

Interview with the Administrator and Director of Nursing(DON) on 03/03/23 at 11:35 A.M. confirmed Resident #1 did not receive the medication Paxlovid from the pharmacy in a timely manner. The physician was notified of the medication request on 02/17/23 and did not respond until 02/19/23. One dose of the medication was administered during the evening of 02/20/23 and not administered again until 02/23/23 in the evening due to a transcription error. The DON verified the primary pharmacy was unable to obtain the medication and attempted to contact a secondary pharmacy that was unable to obtain the medication. No communication from the pharmacy was provided to the facility until 02/19/23 regarding the status of the medication.

Review of Paxlovid manufacturer indications for use, revised February 2023, instructed to initiate Paxlovid treatment as soon as possible after diagnosis of COVID-19 and within five days of symptom onset.

This deficiency represents non-compliance investigated under Master Complaint Number OH00140774.

Based on medical record review, observation, and staff interview, the facility failed to ensure nail care and grooming was provided to a dependent resident. This affected one (Resident #7) of one resident reviewed for activities of daily living (ADLs). The facility census was 19.

Findings include:

Medical record review revealed Resident #7 admitted to the facility on 03/21/22 with the diagnoses including, hepatic failure, osteoarthritis, gastrostomy, dysphagia, dementia, protein calorie malnutrition, acute kidney failure, pancytopenia, glaucoma, depression, hypertension, and hypothyroidism.

According to the Minimum Data Set (MDS) assessment dated 07/15/22, Resident #7 had severe cognitive impairment and was dependent on staff for the completion of ADLs.

Review of the care plan dated 07/22/22 revealed Resident #7 had ADL self-care deficit and physical mobility deficit related to decrease in ability to perform ADLs, difficulty with mobility, and increase dependence for most ADLs. Interventions included the following: ensure glasses are clean, assistance with mobility as needed, check nail length, trim and clean on bath day and as necessary and report any changes to the nurse, requires total dependence of one person with bathing, totally dependent to reposition and move in bed with assistance of two persons, assist to choose simple comfortable clothing that enhances ability to dress self, totally dependent with dressing with the assistance of one person, brush teeth, rinse mouth with wash, requires total dependence with assistance of one person for toileting, and encourage to participate to the fullest extent possible with each interaction.

Review of task completion documentation from 07/26/22 to 08/24/22 noted Resident #7 required full staff performance and was totally dependent upon staff for the completion of maintaining personal hygiene.

Observations on 08/22/22 at 12:51 P.M. and 3:51 P.M. noted Resident #7 in bed wearing a hospital gown. The resident had matted hair to the back of her head, lips with pealing skin and oral cavity with dry mucous membranes, a dark substance under fingernails of both hands, and multiple grey hairs to her chin measuring approximately one inch.

Observations on 08/23/22 at 8:55 A.M., 11:46 A.M., and 3:18 P.M. noted Resident #7 in bed a shirt with an adult brief without pants. The resident had matted hair to the back of her head, lips with pealing skin and oral cavity with dry mucous membranes, a dark substance under fingernails of both hands, multiple grey hairs to her chin measuring approximately one inch.

Observations 08/24/22 at 6:10 A.M. and 9:16 A.M. noted Resident #7 in bed wearing hospital gown. The resident had matted hair to the back of her head, lips with pealing skin and oral cavity with dry mucous membranes, a dark substance under fingernails of both hands, and multiple grey hairs to her chin measuring approximately one inch. The resident had glasses on and the lenses had a film and debris to the lens surface.

Interview and observation on 08/24/22 at 9:30 A.M. with State Tested Nurse Aide (STNA) #431 verified Resident #7 had long hair on her face, matted hair to her head, dark substance under fingernails to both hands, dry oral cavity with dry skin clinging to the lips and debris to glasses. STNA #431 verified providing care to Resident #7 on 08/23/22 and 08/24/22. STNA #431 stated the resident was resistant to personal care, however, she did not report the resistant interactions to the nurse for further guidance.

Interview on 08/24/22 at 9:20 A.M. with the Director of Nursing verified Resident #7 was dependent upon staff for the completion of ADLs and confirmed the resident was not provided sufficient care to carry out ADLs.

Based on medical record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure fall interventions were in place as care planned. This affected one (Resident #10) of two residents reviewed for falls. The facility census was 19.

Findings include:

Review of Resident #10's medical record revealed an admission date of 07/22/22. Diagnoses included Parkinson's disease, heart disease, alcohol abuse, depression, protein calorie malnutrition, cognitive communication deficit, and repeated falls.

Review of Resident #10's Minimum Data Set (MDS) dated 07/26/22 revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating Resident #10 was cognitively intact. Resident #10 required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Resident #10 displayed no behaviors during the review period. Resident #10 was noted to have had a fall prior to admission but none at the time of the review.

Review of Resident #10's care plan revised 08/01/22 revealed supports and interventions for self-care deficit and the resident was at risk for falls. Fall interventions included anticipating needs, ensuring his call light was in reach, and ensure he had access to a working and reachable call light.

Review of Resident #10's Fall Risk Assessment dated 07/22/22 revealed Resident #10 was at high risk for falls.

Observation on 08/22/22 at 10:35 A.M. of Resident #10 found him in his room alone, seated on the front edge of the seat of his wheelchair, leaning forward out of his wheelchair, reaching down toward the floor. Resident #10 was unstable and appeared close to falling. Coinciding interview with Resident #10 revealed he was trying to reach his call light. Resident #10 reported he was looking for it and when he found it, it was stuck under the recliner. Resident #10 stated he was not sure how it got there or how long it was there but he needed to have it. A sign was noted on the wall of Resident #10's room reminding Resident #10 to use his call light for assistance. Closer inspection of the call light found it was stuck in the gears of the recliner.

Interview on 08/22/22 at 10:40 A.M. with Physical Therapist (PT) #454 verified Resident #10 was at risk for falls, his call light was not in reach and the call light was stuck in the gears of his recliner. PT #454 dislodged the call light chord and provided the call light to Resident #10.

Review of the facility policy titled, Falls Management revised 12/03/19 revealed the facility was to institute interventions to prevent a further fall.

Based on observation, staff interview, medical record review and review of the medication administration policy, the facility failed to ensure two medications of 26 were provided within prescribed timeframe's, resulting in a medication error rate of 7.69 percent (%). This affected one (Resident #7) of four residents reviewed for medication administration. The facility census was 19.

Findings include:

Observation on 08/23/22 at 11:40 A.M. noted Registered Nurse (RN) #429 obtained Resident #7's medications from the medication cart to prepare them for gastrostomy tube (G-tube) administration. Medications included omeprazole suspension two milligrams (mg) per (/) one milliliter (ml) equaling 10 ml in a medication cup and Lorazepam 0.5 mg crushed and placed into a medication cup. RN #429 proceeded to Resident #7's room and administered the medications via G-tube. Interview with with RN #429 revealed the medications were ordered twice daily by the physician and were scheduled for 10:00 A.M. However, RN #429 was running behind.

Review of Resident #7's physician orders revealed an order dated 05/06/22 for omeprazole suspension two milligrams (mg) per (/) one milliliter (ml) equaling 10 ml to be administered every day shift between and evening shift.

No specified times were included. Continued review revealed an order dated 08/16/22 for Lorazepam 0.5 mg administered two times a day for anxiety and restlessness. Scheduled times were 10:00 A.M. and 9:00 P.M.

Review of the Medication Administration Record (MAR) revealed the omeprazole suspension was scheduled for 6:00 A.M. and 2:00 P.M. and Lorazepam was scheduled for 10:00 A.M. and 9:00 P.M.

Interview on 08/24/22 at 3:05 P.M. with the Director of Nursing verified Resident #7's medications were not administered within established timeframes.

According to medication administration policy revised on 08/30/16, medications ordered two times daily are administered at 9:00 A.M. and 5:00 P.M. with an hour time before and after the designated times.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure frozen food was stored in a safe and sanitary manner and ventilation ducts were kept clean. This had the potential to affect all 19 residents in the facility. The facility census was 19. Findings include: Observation on 08/22/22 at 9:33 A.M. of the walk in freezer found ice build up along the edge of the door, preventing the door from closing properly. Ice was built up on the inside of the door and covered the bars and racks on the shelving unit along with the boxes of food items on the shelves. The food items were not able to be identified due to the ice build up. Removal of some of the ice crystals from the front of the boxes found they contained breadsticks, pretzel buns, burritos, strawberry rhubarb pie, cherry pie and whipped topping. Also, boxes were found being stored on the floor containing chicken and tiramisu desserts. In addition, a large box of frozen peas was found to be open, uncovered, and unlabeled. Interview on 08/22/22 at 9:36 A.M. with Dietary Manager (DM) #419 verified the peas were not in use and were most likely left open from the day before, the boxes of chicken and tiramisu were stored on the floor and there was ice built up on the side of the door, the shelves, and food boxes. DM #419 reported the seal on the door most likely needed to be replaced again or one of the staff did not ensure it was closed tightly. Observation on 08/23/22 at 9:56 A.M. of the walk in freezer found ice build up continued to be on the inside of the door, the shelves, and breadsticks, pretzel buns, burritos, strawberry rhubarb pie, cherry pie, and whipped topping. 2. Observation on 08/22/22 at 9:27 A.M. of the ceiling ducts above the preparation area in the kitchen and dishwashing area, found dusty-brown/gray buildup, consistent with the appearance of dust, on the ventilation slats of the duct work. Interview on 08/22/22 at 9:30 A.M. with DM #419 verified there was dust build up on the ventilation duct work. DM #419 reported the local health department had completed an inspection and noted the same concern. DM #419 reported maintenance completed the cleaning of the vents and she would make a report again to have them address the dust as she did not think it had been taken care of from the previous inspection. Interview on 08/25/22 at 12:15 P.M. with the Administrator revealed the walk in freezer was last serviced on 06/30/22. The Administrator showed photographs of the ventilation ducts having been cleaned of dust. The Administrator provided documented training that was held on 06/09/22 which included a server cleaning schedule and cook duties. None of the training included cleaning of the walk in cooler/freezer or the vents. The Administrator reported they had no food borne illnesses, and no complaints from resident council regarding food. Review of the Food Inspection Report dated 04/21/22 revealed the local health department had a non-critical finding of build up on the shelving in the the walk in cooler and observed build up on fan and ceiling in the dish wash area. Review of the facility policy titled, Food Storage and ProcurementBased on observation, staff interview, and review of facility policy, the facility failed to ensure frozen food was stored in a safe and sanitary manner and ventilation ducts were kept clean. This had the potential to affect all 19 residents in the facility. The facility census was 19.

Findings include:

Observation on 08/22/22 at 9:33 A.M. of the walk in freezer found ice build up along the edge of the door, preventing the door from closing properly. Ice was built up on the inside of the door and covered the bars and racks on the shelving unit along with the boxes of food items on the shelves. The food items were not able to be identified due to the ice build up. Removal of some of the ice crystals from the front of the boxes found they contained breadsticks, pretzel buns, burritos, strawberry rhubarb pie, cherry pie and whipped topping. Also, boxes were found being stored on the floor containing chicken and tiramisu desserts. In addition, a large box of frozen peas was found to be open, uncovered, and unlabeled.

Interview on 08/22/22 at 9:36 A.M. with Dietary Manager (DM) #419 verified the peas were not in use and were most likely left open from the day before, the boxes of chicken and tiramisu were stored on the floor and there was ice built up on the side of the door, the shelves, and food boxes. DM #419 reported the seal on the door most likely needed to be replaced again or one of the staff did not ensure it was closed tightly.

Observation on 08/23/22 at 9:56 A.M. of the walk in freezer found ice build up continued to be on the inside of the door, the shelves, and breadsticks, pretzel buns, burritos, strawberry rhubarb pie, cherry pie, and whipped topping.

2. Observation on 08/22/22 at 9:27 A.M. of the ceiling ducts above the preparation area in the kitchen and dishwashing area, found dusty-brown/gray buildup, consistent with the appearance of dust, on the ventilation slats of the duct work.

Interview on 08/22/22 at 9:30 A.M. with DM #419 verified there was dust build up on the ventilation duct work. DM #419 reported the local health department had completed an inspection and noted the same concern. DM #419 reported maintenance completed the cleaning of the vents and she would make a report again to have them address the dust as she did not think it had been taken care of from the previous inspection.

Interview on 08/25/22 at 12:15 P.M. with the Administrator revealed the walk in freezer was last serviced on 06/30/22. The Administrator showed photographs of the ventilation ducts having been cleaned of dust. The Administrator provided documented training that was held on 06/09/22 which included a server cleaning schedule and cook duties. None of the training included cleaning of the walk in cooler/freezer or the vents. The Administrator reported they had no food borne illnesses, and no complaints from resident council regarding food.

Review of the Food Inspection Report dated 04/21/22 revealed the local health department had a non-critical finding of build up on the shelving in the the walk in cooler and observed build up on fan and ceiling in the dish wash area.

Review of the facility policy titled, Food Storage and Procurement

Based on medical record review, observation, staff interview, review of facility policy, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure facility staff wore proper Personal Protective Equipment (PPE) when in contact with a resident on Transmission-Based Precautions (TBP). This affected one (Resident #12) of two residents reviewed for TBP. The facility census was 19. Findings include: Medical record review revealed Resident #12 admitted to the facility on 07/24/22 with the diagnoses including, gangrene to right leg, right foot amputation, anxiety disorder, peripheral vascular disease, hypothyroidism, history of venous thrombosis and embolism, hypertension, chronic obstructive pulmonary disease, lymphedema, macular degeneration, and myocardial infarction. According to the Minimum Data Set (MDS) assessment dated 07/28/22, Resident #12 was alert, oriented, and able to make needs known. The resident was dependent on staff for the completion of activities of daily living. Further review of the medical record revealed no documentation indicating Resident #12 was vaccinated for COVID-19. Review of Resident #12's physician orders revealed an order dated 08/18/22 for Resident #12 to be placed in COVID-19 isolation per facility protocol due to unvaccinated status. Observation on 08/22/22 at 3:47 P.M. noted Resident #12 in their room with a sign posted on the door noting the resident was in droplet isolation. There was a cabinet with PPE placed outside the door. Observation on 08/23/22 at 1:10 P.M. revealed Registered Nurse (RN) #429 was observed in Resident #12's room, standing at the bedside. RN #429 was wearing a face shield and N95 mask. RN #429 was not wearing any additional PPE, including gloves or a gown. The droplet isolation sign was still posted to Resident #12's door. Interview on 08/23/22 at 3:50 P.M. with RN #429 confirmed when in Resident #12's room, staff were to wear full PPE due to the resident being in droplet isolation. RN #429 stated she was unaware full PPE was required when in the residents room. Interview on 08/24/22 at 8:03 A.M. with the Director of Nursing (DON) verified RN #429 was required to wear full PPE (gown, gloves, eye protection, and N95 mask) when entering and working with Resident #12. The DON indicated due to the resident being unvaccinated for COVID-19 and going out to appointments in a healthcare setting on 08/22/22, the resident was in droplet isolation for seven days. Additional observation on 08/25/22 at 6:14 A.M. noted State Tested Nurse Aide (STNA) #440 in Resident #12's room assisting the resident at the bedside. STNA #440 was wearing surgical gloves, an N95 mask, and a face shield applied. STNA #440 was not wearing a gown. Interview on 08/25/22 at 6:20 A.M. with the DON verified STNA #440 should have applied all PPE, including a gown due to Resident #12 being placed on droplet isolation. According to the facility's COVID-19 policy dated 02/07/22 revealed new residents or those that have been readmitted and are not up to date with vaccines, are required to quarantine in their private room with transmission based precautions on the appropriate unit, for 10 days or seven days with a negative test within 48 hours or longer if showing signs and symptoms. Place precaution signage on resident door. Personal Protective Equipment (PPE) required includes: Gloves, isolation gowns, facemask, respiratory protection N95 masks or equivalent are recommended, eye protection that covers both the front and sides of the face, hand hygiene using Alcohol Based Hand Sanitizer before and after all patient contact, contact with infectious material and before and after removal of PPE, including gloves if hands are soiled, washing hands with soap and water is required for at least 20 seconds. Review of CDC guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) PandemicBased on medical record review, observation, staff interview, review of facility policy, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure facility staff wore proper Personal Protective Equipment (PPE) when in contact with a resident on Transmission-Based Precautions (TBP). This affected one (Resident #12) of two residents reviewed for TBP. The facility census was 19.

Findings include:

Medical record review revealed Resident #12 admitted to the facility on 07/24/22 with the diagnoses including, gangrene to right leg, right foot amputation, anxiety disorder, peripheral vascular disease, hypothyroidism, history of venous thrombosis and embolism, hypertension, chronic obstructive pulmonary disease, lymphedema, macular degeneration, and myocardial infarction.

According to the Minimum Data Set (MDS) assessment dated 07/28/22, Resident #12 was alert, oriented, and able to make needs known. The resident was dependent on staff for the completion of activities of daily living.

Further review of the medical record revealed no documentation indicating Resident #12 was vaccinated for COVID-19.

Review of Resident #12's physician orders revealed an order dated 08/18/22 for Resident #12 to be placed in COVID-19 isolation per facility protocol due to unvaccinated status.

Observation on 08/22/22 at 3:47 P.M. noted Resident #12 in their room with a sign posted on the door noting the resident was in droplet isolation. There was a cabinet with PPE placed outside the door.

Observation on 08/23/22 at 1:10 P.M. revealed Registered Nurse (RN) #429 was observed in Resident #12's room, standing at the bedside. RN #429 was wearing a face shield and N95 mask. RN #429 was not wearing any additional PPE, including gloves or a gown. The droplet isolation sign was still posted to Resident #12's door.

Interview on 08/23/22 at 3:50 P.M. with RN #429 confirmed when in Resident #12's room, staff were to wear full PPE due to the resident being in droplet isolation. RN #429 stated she was unaware full PPE was required when in the residents room.

Interview on 08/24/22 at 8:03 A.M. with the Director of Nursing (DON) verified RN #429 was required to wear full PPE (gown, gloves, eye protection, and N95 mask) when entering and working with Resident #12. The DON indicated due to the resident being unvaccinated for COVID-19 and going out to appointments in a healthcare setting on 08/22/22, the resident was in droplet isolation for seven days.

Additional observation on 08/25/22 at 6:14 A.M. noted State Tested Nurse Aide (STNA) #440 in Resident #12's room assisting the resident at the bedside. STNA #440 was wearing surgical gloves, an N95 mask, and a face shield applied. STNA #440 was not wearing a gown.

Interview on 08/25/22 at 6:20 A.M. with the DON verified STNA #440 should have applied all PPE, including a gown due to Resident #12 being placed on droplet isolation.

According to the facility's COVID-19 policy dated 02/07/22 revealed new residents or those that have been readmitted and are not up to date with vaccines, are required to quarantine in their private room with transmission based precautions on the appropriate unit, for 10 days or seven days with a negative test within 48 hours or longer if showing signs and symptoms. Place precaution signage on resident door. Personal Protective Equipment (PPE) required includes: Gloves, isolation gowns, facemask, respiratory protection N95 masks or equivalent are recommended, eye protection that covers both the front and sides of the face, hand hygiene using Alcohol Based Hand Sanitizer before and after all patient contact, contact with infectious material and before and after removal of PPE, including gloves if hands are soiled, washing hands with soap and water is required for at least 20 seconds.

Review of CDC guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic