City View MultiCare Center: COVID-19 Summary

A complaint investigation of City View MultiCare Center was conducted by the Illinois Department of Health on October 13, 2015. During this survey, City View MultiCare was found to be in violation of several regulations relating to infection control when the facility failed to follow lice isolation procedures, thus exposing a number of other residents. In response, the nursing home issued a plan of correction, which indicated that the facility would be conducting in services regarding skin infestation, prevention, and infection control. Further, the facility noted that it’s Director of Nursing, or a designee, would be conducting random audits to ensure that residents experiencing skin infestations were properly treated and the spread of transmissible agents was prevented. Ultimately, however, these interventions were not adhered to, as evidenced by a subsequent recertification survey of City View conducted in August 2019.

In an annual recertification survey conducted by the Illinois Department of Health as recently as August 15, 2019, City View MultiCare Center was found to be in violation of several regulations, including those dealing with the facility’s administration of a number of infection and control procedures. Based on observations, interviews, and record reviews performed as a part of that survey, officials noted that the facility failed to ensure that staff performed hand hygiene while administering medication, failed to ensure that staff did not perform multiple tasks with the same gloves, and failed to provide hand hygiene prior to dining.

In two such reported occurrences, staff failed to appropriately sanitize blood glucose monitors. During the first occurrence, staff used a bleach wipe to wipe the machine for two seconds, not allowing the machine time to dry, before using it to perform a test on a resident. Additionally, the staff member used the same gloves he had used while sanitizing the machine to perform the test on the resident. Following the test, he placed the machine in the top drawer of his medication cart.

The second instance occurred just minutes later. After performing another test on another patient using a different blood glucose machine, the staff member sanitized the second machine with a bleach wipe for four seconds, then removed the first machine from the top drawer of his medication cart and sanitized it with a bleach wipe for three seconds, not waiting for the machines to dry before storing them in the top drawer of the medication cart. Ultimately, following these occurrences, the Director of Nursing indicated that the blood glucose monitors should be wiped with a bleach wipe before being wrapped in a bleach wipe.

Additionally, the same survey also noted several instances involving the staff’s hand hygiene and the wearing of gloves. In one instance, a staff member dropped two gloves while walking in the hallway, which he proceeded to pick up and put in his pocket. The staff member then entered a residents room where he did not perform hand hygiene and used the same gloves he had previously dropped on the floor to perform the test. Further, at the completion of the test, the staff member also failed to perform hand hygiene.

Similarly, a different staff member was cited the following day as administering morning medications without performing hand hygiene. After the staff member accidentally dropped a resident’s medication on the surface of the medication cart, she handled the pill with her bare hand before placing it in a medication cup. The staff member also did not perform hand hygiene after administering the medication and prepared and administered medication to two other residents in succession without performing hand hygiene.

Further still, the official conducting the survey also noted the use of gloves during food service. In this instance, a staff member was noticed removing and dropping gloves on the floor when packing up the pans after serving food. The staff member did not perform any hand hygiene prior to packing up the food, and his hand was visibly noted with sweat. Ultimately, these deficient practices affected seven residents reviewed for infection control in a total sample of 112 residents.

In response to these violations, City View MultiCare Center submitted a plan of correction, in which it established corrective actions such as providing in service to all staff members regarding infection control and hand hygiene per policy and procedure. Additionally, the facility noted that it would be implementing a monitoring system in which either the Director of Nursing or a designee would audit compliance on randomly selected residents or employees as frequently as three times per week for one month, followed by two times a week for one month.

Founding partner Steven M. Levin described these outbreaks in many Illinois Nursing Homes: “for many years prior to this outbreak, City View MultiCare Center operated with insufficient staff and with a lack of adherence to recognized infection control protocols.  It is not surprising that they were ill equipped to handle this outbreak.”