Infection Control: Outbreak Plan

It is the policy of Rose Garden Nursing and Rehabilitation Center to have an infection prevention plan that: Identifies the spread of facility infections, Measures to isolate and contain the spread of infection, Reports to appropriate agencies in the event an infectious outbreak occurs.

Procedure: 

Background Reference: 

• Known infections or residents with s/s of infection are identified via: direct observation, vitals, labs, radiology, resident assessment, resident communication, family assessment of resident condition.

• All residents who have community based infections upon admission at Rose Garden are treated from the time of admission for the infection as per physician orders, monitoring orders, isolation orders (if applicable).

• Residents who develop signs or symptoms of infection will be reported to the physician for further instructions regarding orders for monitoring, labs, radiology.

• Regardless of the origin of the infection, communication is provided to direct care staff, the resident representative, physician and other departments who may come in contact with the resident. Communication to staff is done: verbally, via 24 hour report, triage report, isolation signage for the resident room, isolation icon on EMR. Other departments are informed via: signage on resident rooms and daily morning report.

• Standard precautions adhered to unless transmission-based protocol is warranted

An outbreak is defined as any infectious event that is above the usual baseline established by historical infection control rates for the facility.  An outbreak may be a cluster of residents who share similar signs and symptoms that are above baseline. An outbreak may also be a singular event affecting 1 person that poses a physical threat of spread of the infection to others. 

In the event of an outbreak the Director of Nursing, Infection Preventionist and Medical Director will take the lead in collecting and analyzing data. All departments will be notified that an outbreak has occurred and measures to control the outbreak will be developed in a rapid manner.  Resident safety measures taken to mitigate spread may include but are not limited to:

• Isolation: Maintaining care to the resident in the comfort of their room until they are asymptomatic, and the duration of the incubation period is complete
• Cohorting residents by diagnosis and/or symptoms
• Daily monitoring of resident condition as per facility protocol
• Staff education; hand hygiene, PPE, standard infection control guidelines
• Housekeeping intervention to target identified areas (clusters) of infection for deep daily cleaning in rooms and common areas
• Adherence to physician orders regarding medications, labs and radiology for those affected and those potentially exposed
• Daily line list and IDT meetings for close monitoring and communication
• Continuity of staff; avoidance of floor rotation; dedicated staff
• Closing of common areas or restrictions to large common areas
• Disposable food delivery if applicable
• Providing room activities

Quarantine Guidelines

Should an outbreak occur that is highly contagious and poses a direct threat of transmission to others the facility may make the decision to go into quarantine until the threat has ended. The decision to go into quarantine is made with the guidance of the Ocean County Board of Health and Department of Health.

In the event of a quarantine, the facility shall publicly post in the front lobby quarantine procedures and the reason for the quarantine.  Family members, visitors, vendors, contractors and all others will be strongly advised to defer from visitation until the quarantine is lifted. If dictated by the OCBOH or NJDOH the facility will totally restrict visitors, vendors and non-essential personnel.

• Resident representatives shall also be notified via Voice Friend of the quarantine.
• All common areas affected by the quarantine will be temporarily closed.
• Measures stated above to prevent the spread of infectious organisms will be implemented.

The Infection Preventionist, Director of Nursing and Medical Director will oversee adherence to quarantine guidelines and will work the Ocean County Board of Health, Department of Health and any other agency required to manage the care and appropriate medical interventions to care for those afflicted and prevent the spread to others who may have been exposed.

Covid-19 Specific Outbreak Policy

Summary of Lessons Learned:

In March 2020 NJ experienced an outbreak of the novel Coronavirus (aka Covid-19) which swept through long term care facilities causing mass illness and death. Rose Garden has consistently followed directives from Federal and State agencies to prevent the entry and transmission of Covid-19. We welcome new guidance as more is learned about the virus from scientific experts and our administrative staff is engaged in continued education.

The primary components that have proved an effective means of preventing the entry and spread of the virus are: Testing, Cohorting, PPE,  enhanced environmental cleaning and staff/resident/family education. As we move forward there are still challenges that face long term care facilities.

The information below are the current procedures that we have in place.

Employee/Vendor/Visitor Screening

1. All employees/vendors/visitors are screened as per NJDOH/CDC/CMS guidelines prior to entering the facility. Initial screening is done prior to employees entering the facility.
2. Temperature checks are done upon entry and exit of all employees/visitors/vendors.
3. Employees/visitors/vendors who do not pass the initial screening are not permitted into the facility.
4. Visual aides for screening and education are provided both inside and outside of the facility.

Cohorting

1. Residents will be cohorted by wing/designated area based on symptoms and testing
   1. Ill wing – Residents who have tested +
   2. Exposed wing- unvaccinated/exposed residents who are not “up to date” with current booster.
   3. Well wing – Residents who have tested negative and are asymptomatic with no/low risk of exposure

Testing 

1. Employees who test + will be prohibited from work for a minimum of 10 days
2. All new admissions are requested to be tested for Covid prior to admission
3. All new admissions who have tested negative for Covid-19 will be placed on an “exposed” wing with transmission based precautions for a minimum of 7 days if unvaccinated
4. Residents who test + for covid will be transferred to the “ill” unit OR will be treated in place if there are multiple residents on 1 wing who test positive.
5. All residents who test + for covid will be kept on Enhanced transmission Covid isolation for a minimum of 10 days.
6. Staff members provide verbal consent for testing/results at the point of testing. Staff members who receive off-site testing voluntarily provide their test results. The facility does not call private/public labs to obtain results.
7. Staff members who test positive for COVID-19 , refuse testing or who choose to  not provide testing results to the facility are excluded from work.
8. Return to work protocol: Staff members who test positive for COVID-19 must be symptom free and post Covid for 5 days
9. Contingency staffing plans are in place and located in the facility assessment.

PPE

All employees, visitors and vendors are provided with appropriate PPE as recommended by the CDC/OSHA, and per the facility infection control guidelines.

Admissions/Readmissions:

All unvaccinated admissions or residents who are considered not “up to date” with current booster will be assigned to the exposed wing and kept on transmission precautions for 7 days. Full PPE is provided and is to be donned/doffed per resident on the exposed wing.

The definition of “up to date on vaccination” per the CDC, in the United States,  is individuals who have completed a primary series and received all recommended booster vaccines based on age and comorbidities. Those who have received a primary series but are not yet eligible for the booster vaccine because of age or timing of the last vaccine dose are still considered up to date.

The CDC had also used the term “fully vaccinated” to refer to individuals who had completed the primary COVID-19 vaccine series at least two weeks prior. However, since the introduction of booster vaccines, public health recommendations have evolved to focus on whether individuals are up to date on vaccination as detailed above.

Covid -19 Units:

PPE is provided to any team member entering the Covid isolation units. Full PPE is provided and is to be donned/doffed per resident.  Disposable PPE is discarded in isolation trash bins.

PPE:

• Isolation PPE:  Face shield/goggles, N-95s,  gowns and gloves
• Discard: Plastic gowns, hair caps, N-95 and gloves in isolation disposal cart
• Hair covering caps are also available for team members and encouraged

N95s:

•  N95s are to be used at all times on the Covid and exposed wing. The supply of N95s are universal size. Fit testing is done prior to N95 use.
• N95 masks are used with a surgical mask on top. Surgical masks are removed/replaced between patient care.

Face Shields:

• Goggles/face shields are distributed to all direct care workers
• Goggles/face shields are disinfected with FDA approved cleaner between each use
• Goggles/face shields are available to ALL staff members and are replaced if broken or unusable for any reason

Gowns:

• Disposable gowns are available to all direct care staff providing care to residents on isolation precautions
• Instructions for Obtaining needed PPE
• Face shields/goggles have been distributed to all direct care staff and are supplied to any new employee from Central Supply
• N95, gowns and gloves are provided in bins outside each isolation room
  • For Ill and Exposed wing: disposable gowns are changed before/after care for each resident.

Source Contact:

Surgical Masks/face covering provided to residents (if tolerated) during direct care.

Resident Mask Use:

• Residents who leave their room are encouraged to use a mask or face covering.
• Masks are donned by residents who are being transferred to/from the facility
• Masks are donned by residents whenever they are accompanied by staff to any part of the facility

Communication to Families:

Family notification of newly positive residents or staff is done via Voice Friend which is an email listserv communication software service. Families are notified by 5pm the next calendar day if there is a single confirmed infection of Covid-19 or whenever three or more residents or staff with new-onset respiratory symptoms occur within 72 hours of each other.

Communication to Residents:

Residents receive written communication if there is a single confirmed infection of Covid-19 or whenever three or more residents or staff with new-onset respiratory symptoms occur within 72 hours of each other. Written communication is also provided for any change in facility policy related to the current Covid-19 restrictions. Additionally, residents are provided with verbal daily and/or weekly updates from their social worker.

Virtual Visitation: 

Rose Garden offers virtual communication via phone, video-communication ( Facetime, Skype)  and traditional mail. The Virtual Visitation Coordinator is the Social Service Directors who schedule virtual communication visits. Virtual visits are scheduled daily.

Visitation: 

Visitors must be allowed for all residents at all times per CMS QSO-20-39-NH, revised on 11/12/2021. A resident has the right to refuse visitors.

Visitor Screening:

All visitors are screened as per NJDOH/CDC/CMS guidelines prior to entering the facility.

Visitors must comply with Rose Garden’s policies during visitation, which include:

1.Wearing well fitted face mask

2. Performing hand hygiene with alcohol-based hand rub or soap and water.
3. Practicing social distancing from other residents

Visitation areas:

Visitation is recommended to be conducted in the resident’s room and social distanced from other staff/residents when possible. If visiting in a common area, social distancing is required from others. Dining is permitted with the resident, must be at a separate table six feet from other residents/staff.

Staffing Contingency Plan:

In the event that an outbreak occurs at Rose Garden that has a direct impact on staffing the following actions will be taken:

1. Incident Command set up to insure coordination between departments
   1. Set up means of communication for Dept heads, staff, families, residents, Medical Director, facility physicians, essential vendors
      1. Group text
      2. Conference calls
      3. Email chains
      4. Voice Friend
      5. Face to face verbal communication
2. Triage resident care needs
   1. Staffing requirements
      1. Nursing- In the event of a catastrophic nursing shortage all restorative staff, administrative nurses, activity personnel who are CNAs/HHAs will be assigned on the floor
      2. CMS/DOH waivers: In the event of an emergency that warrants staffing waivers such as in the case of Covid-19 vigorous recruitment efforts via employment websites and social media will offer employment opportunities within the guidelines of such stated waivers.
         1. Covid-19: Recruitment of TNAs as per waiver
         2. Covid-19: Recruitment of HHAs as per waiver
   2. Medication Reduction
      1. Attempt to reduce non-essential medications and txs to provide more direct nursing care
   3. Equipment Requirements
   4. PPE Requirements
      1. Burn rate calculator use by purchasing agent
3. Guidance and Education
   1. Team members will participate in educational briefings from regulatory agencies such as : COCA calls, DOH briefings, CMS briefings. The assistant administrator will coordinate the team to ensure that timely information is available.  Policies will be adjusted as guidance dictates.

Emergency Staffing Minimum (based on census of 115)

Nursing Day Shift 

Nursing Evening Shift 

Nursing Night Shift 

Administrative Nurses:

In the event of an emergency administrative nurses may be called on to provide direct resident care

-Director of Nursing

-Clinical Care Coordinator

-MDS Coordinator

-MDS Med A nurse

-Nurse Practitioner for Optum residents

Staffing Plan – Dietary

Staffing Plan- Activities

Housekeeping Staffing Plan

Maintenance Staffing Plan

Social Services Staffing Plan

Therapy Staffing Plan

Administrative Staffing:

All administrative staff necessary for the essential functioning of the facility will remain actively working on or off site.

**CDC Guidance -Crisis Capacity Strategies to Mitigate Staffing Shortages

When staffing shortages are occurring, healthcare facilities and employers (in collaboration with human resources and occupational health services) may need to implement crisis capacity strategies 000to continue to provide patient care.

When there are no longer enough staff to provide safe patient care:

• Implement regional plans to transfer patients with COVID-19 to designated healthcare facilities, or alternate care sites with adequate staffing
  • Rose Garden has an agreement with Arbors Care Center, Complete Care @ Holiday City, Complete Care @ Shorrock Gardens and Harrogate for the transfer of residents in the event that transfer is necessary
• If shortages continue despite other mitigation strategies, consider implementing criteria to allow HCP with suspected or confirmed COVID-19 who are well enough to work but have not met all Return to Work Criteria to work. If HCP are allowed to work before meeting all criteria, they should be restricted from contact with severely immunocompromised patients (e.g., transplant, hematology-oncology) and facilities should consider prioritizing their duties in the following order:
  • If not already done, allow HCP with suspected or confirmed COVID-19 to perform job duties where they do not interact with others (e.g., patients or other HCP), such as in telemedicine services.
  • Allow HCP with confirmed COVID-19 to provide direct care only for patients with confirmed COVID-19, preferably in a cohort setting.
  • Allow HCP with confirmed COVID-19 to provide direct care for patients with suspected COVID-19.
  • As a last resort, allow HCP with confirmed COVID-19 to provide direct care for patients without suspected or confirmed COVID-19.
• If HCP are permitted to return to work before meeting all Return to Work Criteria, they should still adhere to all Return to Work Practices and Work Restrictions recommendations described in that guidance. These include:
  • Wear a facemask for source control at all times while in the healthcare facility until they meet the full Return to Work Criteria and all symptoms are completely resolved or at baseline. A facemask instead of a cloth face covering should be used by these HCP for source control during this time period while in the facility. After this time period, these HCP should revert to their facility policy regarding universal source control during the pandemic.
    • A facemask for source control does not replace the need to wear an N95 or higher-level respirator (or other PPE) when indicated, including when caring for patients with suspected or confirmed COVID-19.
    • Of note, N95 or other respirators with an exhaust valve might not provide source control.
  • They should be reminded that in addition to potentially exposing patients, they could also expose their co-workers.
    • Facemasks should be worn even when they are in non-patient care areas such as breakrooms.
    • If they must remove their facemask, for example, in order to eat or drink, they should separate themselves from others.
  • Being restricted from contact with severely immunocompromised patients (e.g., transplant, hematology-oncology) until the full Return to Work Criteria have been met.
  • Self-monitoring for symptoms and seeking re-evaluation from occupational health if respiratory symptoms recur or worsen.

Revised 11/3/22