OSDH posts report on deficiencies at Burford Manor during outbtreak

The Oklahoma Department of Health conducted a COVID-19 special focus survey with a complaint investigation at Burford Manor on Nov. 20 and 23 to determine if the facility was in compliance with infection prevention and control requirements. The inspection found substantiated deficiencies in that the facility failed to have adequate staff to meet the standards of the residents and they failed to ensure the staff followed proper infection control procedures.
Inadequate staffing
The facility reported 50 residents in the facility at the time of the inspection. It was reported that there were 35 COVID-19 positive residents in the COVID wing at the end of the inspection.
On Nov. 18, at the beginning of the week, it was reported in The Davis News that there were around 40 positive residents and the facility had faced its first COVID-19 death that morning. Later that afternoon, another COVID-19 death occurred. It is unclear how many residents have passed due to COVID-19 since that time.
The direct care staffing report for September documented staffing shortages for four of the 81 shifts and three of the 93 shifts in October.
Anonymous reports to The Davis News have indicated that employees with any type of medical licenses have been counted toward the total of the required amount of employees on the floor even if they are not working in that capacity (kitchen or office.)
The administrator, Keziah Koshegee, said that contracts had been signed and executed with three staffing agencies within the past two weeks. It’s unknkown how many of those people from the staffing agencies actually worked at Burford Manor during the COVID-19 outbreak and subsequent short staffing period.
According to the report: a licensed practical nurse interviewed on Nov. 20 “reported the facility did not have enough staff to properly care for, assess and document the COVID positive residents. The LPN reported all positive residents had been placed on skilled care services. The LPN identified 28 positive residents who were on skilled care services. The LPN was asked how frequently assessments and vital signs were to be obtained and documented. The LPN reported assessments and vitals were to be completed every shift. The LPN reported it was difficult to complete all skilled assessments, charting and supervise staff.”
Medical record reviews revealed omitted documentation for one resident six of seven days and another seven of seven days on both shifts.
On Nov. 23 the LPN reported all 35 residents in the COVID unit were on skilled care services. The LPN reported five of the 35 residents had not yet had orders noted for admission to skilled care services. The LPN reported not all of the skilled assessments had been completed.
Residents on skilled care services should be receiving some type of therapy. Family members with questions regarding their loved ones being placed on skilled services during this outbreak should contact the nursing home. If a family member, Power of Attorney or guardian so wishes, they can request their loved one’s records for this time period.
Additionally, interviews with family members indicated delays in response times and staff answering call lights taking sometimes an hour and a half.
Infection Control
Procedures
A policy titled, Novel Coronavirus COVID-19, documented the facility would conduct education, surveillance and infection control prevention strategies to reduce the risk of transmission of the Novel Coronavirus. The policy documented staff would apply appropriate PPE (personal protective equipment) to include gloves, gown, isolation mask and eye protection.
Staff were observed to be assisting residents in their rooms without the use of gloves on multiple occasions including refilling water pitchers and assisting a resident with drinking. The Director of Nurses was asked why the staff was not wearing gloves while providing care to COVID positive residents. The DON replied “gloves give a false sense of security . . . . staff washed their hands more frequently when gloves were not worn.”
Several staff members were asked what transmission-based precautions were in place and replied, “full PPE to include gown, N95 respirator, face shield gloves and booties.”
Additional actions of protection included the frequent use of alcohol based hand gel and when asked if they should be wearing gloves one CNA (certified nurses aide) said “they should.”
The MDS (minimum data set coordinator) nurse said that staff had “slacked off” washing hands and using alcohol based hand gel. She also noted the staff needed frequent reminders to utilize PPE.
The maintenance director was asked how frequently biohazard waste was picked up. The maintenance director reported biohazard had been picked up every two weeks and he had requested a more frequent pick up with the increased waste. A locked storage room was reported to have 33 boxes of biohazard waste and another 20 boxes of biohazard waste was stored in an empty resident room in the COVID unit because the locked storage unit was full.
A look over the website www.surveys.health.ok.gov proves one thing, traditionally, Burford Manor has had good surveys and inspections. This report can be viewed in its entirety here as well.
In June, Burford Manor received a surprise inspection for the same reason (without complaints) and passed the inspection. Koshegee spoke with The Davis News about the survey. It was later determined that not all of the staff had their COVID-19 tests done at the time. This could’ve been one reason that the facility didn’t open to visitors.
The nursing home has until Dec. 19 to submit a plan of correction. They could face termination of their Medicare or Medicaid Provider agreements unless the facility achieves substantial compliance before May 23, 2021, and a Civil Money Penalty could be imposed. The nursing home can appeal these findings no later than Feb. 27, 2021.
The state’s Weekly Epidemiology Report shows the same number of cases for Burford Manor as it did last week and has added just seven new cases since the report first began listing nursing homes’ statistics individually on the Oct. 23-29 report.
In the last two weeks, Burford Manor hasn’t answered requests to find out how many residents are still COVID positive, when they might receive COVID vaccines or when the facility might advance to the next phase of visitation.
Sources at OSDH could answer another question for us, as long as case counts are high in the county, they can not open. Burford Manor could do outside visits (weather permitting) but with weather worsening each day that seems like an unreachable goal.

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