Facility has experienced 10 COVID-19 patient deaths
By SUE SUCHYTA
Sunday Times Newspapers
RIVERVIEW – Ten patients have died of COVID-19 at Rivergate Terrace under conditions for which the Michigan Department of Licensing and Regulatory Affairs cited them for putting patients in “immediate jeopardy.”
Seven residents died in the hospital, and three died on site.
Rivergate Terrace, 14141 Pennsylvania Road, a 116-room facility, was issued the highest level of citation which LARA can issue, which released a survey April 15, after an inspection April 10 through 14, which stated that patients were put at risk by the facility’s failure to properly maintain infection control practices.
Multi-use medical equipment, such as blood pressure cuffs, were not sanitized between isolated and non-isolated patients.
In addition, personal protective equipment, which was noted as worn, was stored, hanging in the doorways of 11 confirmed and presumptive positive patients, and the gowns were worn by multiple health care providers, sometimes for up to a week without replacement.
Investigators found that Rivergate Terrace must establish and maintain an infection prevention and control program to provide a sanitary environment and prevent the spread of communicable diseases and infection.
A report issued by the Department of Health and Human Services, Centers for Medicare and Medicare Services, completed April 15, concluded, based on observations, interviews and a review of records, that the facility failed to maintain proper infection control practices during the COVID-19 pandemic.
“The likelihood of further spread of infection, due to improper infection control practices, could lead to serious harm, injury, impairment or death,” the report stated.
A management infection control nurse confirmed to the inspection team that multiple staff members wear the same PPE gowns hanging outside the rooms of isolated patients, to extend the gown life. A certified nursing assistant, the director of nursing and a site administrator confirmed the practice.
On April 10, a social worker was observed wearing a gown and mask into a room with a confirmed COVID-19 infected patient, then entering the room of a non-COVID-19 infected patient wearing the same gown and mask.
The staff development nurse acknowledged the need for staff re-education, and said isolation gowns were reused by multiple staff members to preserve the facility’s limited supply.
A Competency-Evaluated Nursing Assistant, CENA, was seen using a portable cart with a portable blood pressure machine, which also measures heart rate and temperature, who used the equipment in multiple patient rooms without disinfecting the equipment or changing the blood pressure cuff.
A nurse said the patients in the affected rooms were in respiratory isolation, so the equipment was not sanitized between patients. The equipment had only one cuff, and no disinfecting wipe or sanitizing equipment was stored on the cart to clean it between patients.
Another CENA was seen continuing to wear the same PPE gown after leaving a room of a patient in respiratory isolation.
Another employee, a nurse, was questioned as to why he did not immediately disinfect a pulse oximeter, an instrument used to measure the saturation of oxygen in blood cells, after leaving the room of a patient with respiratory precautions. The nurse, who placed the instrument on the cart, then spent several minutes updating medical records, said that he would sanitize it before using it on the next patient.
Another CENA was seen rolling a blood pressure machine out of a room of a patient in respiratory isolation and then went into the room of a patient not in respiratory isolation without sanitizing the blood pressure cuff. When questioned, the CENA said she cleaned the cuff before leaving the isolated patient’s room. However, the cart did not contain any cleaning or sanitizing equipment. When asked what was used to sanitize the cuff, the CENA did not give a direct answer.
Another CENA was seen rolling a blood pressure machine from a respiratory isolation room to a patient not in respiratory isolation without disinfecting the cuff, and said she did not know which patients had COVID-19 and required isolation.
A Certified Nursing Assistant, a CNA, was observed providing care to isolated and non-isolated patients without changing their PPEs.
An assistant director of nursing and unit manager said that CNAs are told to hang gowns on the doors and reuse them “if they are not visibly soiled.”
A CENA was asked if they could tell if the isolation gowns hanging outside the door of a patient room were soiled by looking at them, and they said they could not, and added that some of the gowns had been used for “about a week now.”
On April 10, the LARA inspection team required the facility to remove all PPEs gowns hanging outside patient rooms and use clean, unused gowns. It also required all equipment used on patients to be immediately sanitized with hospital grade disinfectant.
The infection prevention nurse, the director of nursing, the medical director and the executive director were educated with respect to infection prevention and control, outbreak and pandemic control and management policy, and COVID-19 outbreak policy.
Prior to starting their next shift, they were directed to educate all facility staff with respect to the same protocols, as well as be taught about PPE policy, transmission-based precautions and isolation procedures, and the cleaning and disinfection of non-critical patient care equipment.
Michigan, which has approximately 38,000 patients in nursing homes in 442 facilities, have reported more than 7,000 confirmed nursing home COVID-19 cases and nearly 2,000 nursing home resident deaths from the virus.
The Michigan Long Term Care Ombudsman Program, founded in 1972, works to improve the quality of care and quality of life for people in nursing homes, senior facilities and those in adult foster care.
Those concerned about state nursing home practices can contact the Michigan Long Term Care Ombudsman Program at 517-827-8040 or at [email protected] For more information, go to MLTCOP.org.