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06/23/2020 12:00 AMA state Department of Public Health (DPH) inspection of Apple Rehab in Old Saybrook, where 74 residents have tested positive for COVID-19 and 20 have died, has documented violations of state agency regulations and/or Connecticut General Statutes.
The unannounced May 27 visit focused on COVID-19 infection control and the resulting report was uploaded to a state online database in mid-June. Apple Rehab’s plan of correction, signed electronically on June 15, was posted to the database on June 17.
According to the DPH, as of June 16, Old Saybrook had 103 confirmed cases of COVID-19, making the known cases at Apple Rehab more than two-thirds of the total in town.
Inadequate Staff Training
As of the date of inspection, the facility had been without an infection control nurse—the staff member tasked with providing training on infection control to staff—since around December 2019, according to the report. The facility “failed to ensure staff were appropriately educated on transmission-based precautions, on donning and doffing Personal protective equipment (PPE), and on appropriate hand washing techniques during the COVID-19 pandemic,” it states.
In March, 85 staff members were trained in handwashing, but competencies—the process of formally verifying that skills have been attained—were not completed, according to the report. In April, PPE education and “universal masking” training were offered but attended by only 17 and 18 staff members, respectively. Education on properly putting on and taking off PPE was not offered until May 14 and only 18 of 69 members of the nursing staff completed competencies in those skills.
As for training on transmission-based precautions since the onset of COVID-19, rather than an in-service educational session, Apple Rehab had posted informational posters on the wall with “a handwritten note on the bottom indicating that staff should read and sign,” the report states.
Short on Staff
The facility was short staffed, according to the report, with one licensed practical nurse (LPN), one nurses’ assistant (N.A.), and one hospitality aid working in one of the three nursing units; a second N.A. had reportedly called in sick that day.
The inspector(s) observed three patients congregating at a table in the lounge without social distancing and not wearing masks, as well as a fourth patient walking outside his or her room without a mask. All four patients had been diagnosed with dementia (in one case, specifically Alzheimer’s disease).
The N.A. attested to being unable to assist patients by redirecting them to wear masks or properly distance from one another without the assistance of a second N.A., particularly while the LPN was distributing medication. Hospitality aids are not permitted to physically assist patients, according to the N.A. cited in the report.
The report also notes that the facility did not complete a point prevalence survey (PPS), which collects data on infection among patients at a specific point in time, until May 19, 10 days after determining that it had its first COVID-19 case.
According to a June 11 DPH COVID-19 summary, a PPS is a strategy of determining the “infection status of all residents in a facility...so that people who are potentially infectious can be separated from other residents.” A statewide nursing home PPS initiative was begun in early May.
“If the violations are not responded to by June 13, 2020 or if a request for a meeting is not made by the stipulated date, the violations shall be deemed admitted,” the report states.
Apple Rehab’s plan of correction was electronically signed on June 15.
The inspection report notes 79 residents in the facility, which has a capacity of 120. The report does not indicate how many residents as of that date had tested positive for COVID-19. Five days earlier, on May 22, according to information obtained by the town’s Emergency Management Office (EMO), 38 Apple Rehab patients had tested positive and three had died.
As of June 11, according to an EMO COVID-19 update, 69 Apple Rehab patients had tested positive and 19 had died. These figures raise questions as to the current number of residents, if any, who have not tested positive for the virus.
Kerri Kuhn, administrator of Apple Rehab in Old Saybrook, declined to comment. Calls to Apple Rehab headquarters in Avon seeking comment and clarification were not returned.
Plan of Correction
Apple Rehab’s plan of correction does not list specific dates for reforms have been or will be implemented, stating, for instance, that the patients referred to in the inspection report “have facemasks applied when exiting room and social distancing of six feet or greater is maintained.”
The LPN has been educated in “redirecting residents and providing facemask if resident is not wearing one,” it states, and the “facility ensures there is sufficient staffing to implement measures to prevent the transmission of COVID-19,” including ensuring that residents maintain social distancing and wearing masks.
It is unclear as to whether the plan is referring to Apple Rehab’s existing policies, its intentions to remedy violations referred to in the inspection report, or changes that have already been implemented.
The plan promises a “weekly random audit of staffing to ensure there is adequate staffing scheduled” as well as audits of residents to ensure they are maintaining social distancing and wearing masks. “[S]ubstantial compliance” in these areas is promised by Saturday, June 27.
“Nursing staff [is] educated on transmission based precautions, donning and doffing PPE, handwashing and the appropriate use of PPE on COVID positive and quarantine unit,” according to the plan, and nursing staff members “have competencies for donning and doffing PEE and hand washing.” Again, it is unclear as to when competencies were attained and by how many members of the staff.
The plan promises another set of weekly audits “to ensure staff are using PPE correctly on the positive unit and quarantine unit,” that “nursing staff is donning and doffing PPE correctly,” and that “staff are following appropriate hand washing technique.” The date of “substantial compliance” is June 27.
Statewide Third-Party Review
On June 8, Governor Ned Lamont ordered an independent review of nursing and independent living facilities to determine how they have addressed the pandemic. According to a press release from the governor’s office, Lamont “wants the analysis completed before the start of autumn in order to prepare for a potential second wave of the virus.”
Nursing homes and independent living facilities have been particularly hard hit by COVID-19. According to DPH figures, nearly 50 percent of COVID-19 deaths in Connecticut have been of nursing home residents. More than 12 percent of those tested positive across the state live in nursing homes.
Another sobering statistic: Roughly 37 percent of residents of Connecticut nursing homes who contract COVID-19 die. This is compared to 9.3 percent of overall residents.