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25 | On 10/19/20 Licensing Program Analyst (LPA) Chris Hopkins and Licensing Program Manager (LPM) Julio Montes conducted a case management visit to follow up on non compliance conference via telephone dated 9/30/20. LPA and LPM met with Administrator David Wall and Diana Wall RN,BSN,PHN, IP.
During the Technical Assistance inspection with Health Facilities Evaluator Nurse (HFEN) Barbie Henson on Tuesday October 13, 2020, there were 4 caregivers who demonstrated donning and doffing procedures.
The HFEN noted that staff were still lagging in their training in donning and doffing their N95 masks, and all four staff struggled with different areas on the proper use of their Personal Protection Equipment (PPE). A couple of staff tested were not able to discern that the top and bottom straps were crossed, placing the bottom strap over their hair, instead of on skin at the back of their neck. Another staff forgot to untie the gown at the waist and would have contaminated his/her arm and uniform in the manner demonstrated. The facility had not posted the donning and doffing sequence signage recommended during the previous HFEN visit/testing. The CDC sequence indicates the use of hand sanitizer at each step of removing PPE if anything gets contaminated during the process.
It was also noted during this tele-inspection that the room where the demonstration took place did not have hand-sanitizer on hand, as had been recommended during the previous HFEN visit. Although it was explained that the room was not in the isolation area and did not have a resident at the time of the inspection, given the recent emergency the facility just experienced, it is expected that the licensee be ready to act and to receive a resident at moments notice as indicated in the implementation plan. On September 8, 2020, the licensee was asked to complete a mitigation plan to address the shortcomings found during previous inspections by the San Francisco Department of Health (SFDPH) and CDSS. Among other preparations and recommendations, the facility needed to plan for supplying and maintaining hand sanitizers in each room to be able to react appropriately at moment notice.
Report Continued on LIC809-C...
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