COVID-19 Guidance for Long-Term Care Facilities

1. Infection Prevention in Long-Term Care

Staff, Resident and Visitor Screening
All facilities are required to develop an internal policy for how to screen and manage staff, residents, and visitors.
You must maintain a log for all entries to the building and keep those records for 30 days.

  • Review Washington Department of Health’s guidance for screening — DOH
  • Assess all who enter the building (staff, residents and visitors) for COVID-19 symptoms. Review CDC’s current symptom list.
    • Evaluate residents for symptoms at least once per shift.
  • Take the temperature of all who enter the building (staff, residents and visitors).
    • Take residents’ temperatures at least once per shift.
  • Restrict entry and/or immediately isolate any individual with COVID-19 symptoms.

Staff, Resident and Visitor Education
All facilities should display educational materials for staff, residents and visitors.

  • Post visual instructions for the use of facemasks.
  • Post visual instructions for respiratory and hand hygiene.
  • Provide hand sanitizer, face coverings and tissues throughout the facility for staff, residents and visitors.

Staff and Resident Testing
All facilities are required to develop and maintain access to an established commercial lab to conduct ongoing testing of residents and staff.

  • Have a low threshold for testing residents and staff with suspected COVID-19.
    • Cough and fever are not always present in COVID-19 infections.
  • Work with your lab and medical director to have a plan for testing staff or residents with suspected COVID-19.
  • Collect specimens in a closed room to prevent dispersal of droplets. For large-scale staff testing, consider using an outdoor space if weather permits.
    • Staff collecting specimens should wear N95 respirator (or facemask if unavailable), eye protection, gown and gloves.

Additional Strategies

  • Implement telehealth when appropriate.
  • Develop and implement nurse-directed protocols when appropriate.
  • Ensure physical distancing of staff and residents in the facility.

CDC Guidance

2. Personal Protective Equipment (PPE) Use

Mask Up

  • All staff and contractors must wear a facemask in the facility. This includes breakrooms, bathrooms and other spaces where they will encounter co-workers.
    • Respirators with exhalation valves are not recommended for source control and should not be used because exhaled breath is unfiltered.
  • All residents should wear a mask while out of their room or out of the building unless they are having trouble breathing or are incapacitated and unable to remove their own mask without assistance.
  • All visitors, when allowed, must wear a cloth face covering.

Additional PPE

  • Facilities located in areas with moderate to substantial community transmission should add additional precautions.
    • All staff should wear eye protection while in the facility to protect against exposure to respiratory secretions.
    • All staff should wear an N95 during aerosol generating procedures (CPR, intubation, nebulizers), regardless of whether the patient is suspected to have COVID-19.
  • Patients with suspected or confirmed COVID-19 should be on special droplet precautions (respirator or face mask, eye protection, gown and gloves) throughout their isolation.

PPE Conservation

  • Conservation of PPE may involve extended use or reuse of PPE.
    •  Extended use refers to using the same PPE between multiple patients without removing it.
    • Reuse refers to using the same PPE between patients and removing it between interactions or on different days.
  • We are not currently experiencing a critical shortage of PPE, but we are still encouraging strategies that anticipate PPE shortages.
    • Extend the use of or reuse N95 masks for close contact with patients who are not in droplet precautions.
    • Extend the use of disposable gowns or use reusable cloth isolation gowns for close contact with patients who are not in droplet precautions.
    • Use reusable eye protection for close contact with patients who are not in droplet precautions.
    • Do not reuse PPE for patient care activities between COVID-19 positive and COVID-19 negative patients.
  • Review CDC’s recommended strategies to optimize the supply of PPE during contingency capacity.

Donning and Doffing Reusable PPE

  • Review CDC’s guidance and educational materials for donning and doffing PPE
    • Donning sequence: Gown, mask or respirator, goggles or face shield, gloves.
    • Doffing sequence: Gloves, gown, goggles or face shield, mask or respirator.
  • Reusing PPE requires careful donning and doffing to prevent exposure to the healthcare worker.
    • Gloves may be used past their intended expiration date during contingency capacity but should only have extended use during a crisis.
    • Disposable gowns are not recommended to be doffed and reused due to breaking of ties and fasteners.
  • Cloth gowns may be untied and retied without laundering in between.
    1. Carefully untie gown while wearing gloves and pull it forward at the sleeves.
    2. Hang gown in an open area and avoid contact with other garments.
    3. Wash hands.
  • Goggles and face shields can be reprocessed following manufacturer recommendations for cleaning when available. If no manufacturer instructions are available:
    1. Wipe down all surfaces of the goggles or face shield with a detergent solution or cleaner wipe while wearing gloves. For a face shield, wipe the inside first.
    2. Remove the face shield and rinse with water to remove residue.
    3. Set in a clean, dry environment and allow to fully dry.
    4. Remove gloves and wash hands.
  • Respirators (i.e., N95) may be reused throughout a single shift or across multiple days if carefully removed and stored.
    1. Carefully remove respirator without touching the face piece or inside of the mask.
    2. Hang the respirator in a designated storage area or keep in a breathable container (i.e., paper bag).
    3. Wash hands.
  • Facemasks with elastic ear hooks maybe more suitable for re-use than those with ties as ties may break during removal.
    1. Carefully remove facemask without touching the face piece or inside of the mask.
    2. Fold the mask so that the outer surface is held inward against itself.
    3. Place mask in a breathable bag or container.
    4. Wash hands
  • Dispose of all PPE that has been visibly soiled, used during aerosol generating procedures, or used on patients with coinfections that require precautions (i.e., tuberculosis, C-diff, etc.).

Fit Testing
Fit testing is required to ensure respirators work effectively. Contingency and crisis capacity strategies may remove annual fit testing requirements, but initial fit testing with the brand and size of mask is still necessary.

3. Managing Confirmed or Suspected Cases of COVID-19

Health Department Notification

Notify the Health Department of any suspected or confirmed cases of COVID-19 in your facility. Visit our COVID-19 page for more information.

Isolation and Quarantine for Staff and Residents

  • The test-based strategy for discontinuing isolation is no longer recommended, except is rare cases. Use timebased strategies to discontinue transmission-based precautions:
    • Patients with no symptoms who are not severely immunocompromised:
      • Isolate for 10 days from test date.
    • Patients with no symptoms who are severely immunocompromised:
      • Isolate for 20 days from test date.
    • Patients with mild to moderate illness and who are not severely immunocompromised:
      • Isolate for at least 10 days from symptom onset. – Patient must also be fever-free for 24 hours with improved symptoms.
    • Patients with severe to critical illness (i.e., respiratory rate >30, SpO2 < 94%, signs of respiratory failure, septic shock, and/or organ dysfunction) or who are severely immunocompromised:
      • Isolate for 20 days from symptom onset − Patient must also be fever-free for 24 hours with improved symptoms.
        • Please new and return admissions on 14-day quarantine, preferably in a designated unit of the facility.
    • Testing is not recommended as a condition of admission.
  • Review CDC’s guidance on discontinuation of transmission-based precautions.
  • Review CDC’s return to work guidance for healthcare providers.

Outbreak Testing

  • A single case in a resident or staff of a long-term care facility is considered an outbreak.
  • Quickly test all residents and staff in response to an outbreak. This allows for early identification of cases and interventions to isolate infected individuals (including asymptomatic staff or residents).
  • Continue repeat viral testing of all previously negative residents and staff every 3-7 days until no new cases are identified.
  • Review CDC’s testing guidelines for nursing homes.
  • Maintain droplet/contact precautions for confirmed and suspect cases of COVID-19 throughout isolation period.
  • Cohort confirmed COVID-19 patients to conserve PPE.

Patient Transport During an Outbreak

  • If a patient requires transportation out of the facility for a higher level of care, immediately notify EMS and the receiving hospital if:
    • The transferring patient has confirmed or suspected COVID-19.
    • Any patient at the facility has confirmed or suspected COVID-19.
  • Contact the Regional COVID-19 Coordination Center (RC3) whenever 3 or more patients need to be transported out of the facility for a higher level of care.
    • This resource was established to triage and place COVID-19 patients who require acute emergency department or inpatient hospital care. It helps to balance patient placement and transport, so it does not strain a single hospital’s resources.
    • Review the framework and additional information from the Northwest Healthcare Response Network(NWHRN).

4. Special Issues

Memory Care Recommendations

  • Memory care units pose unique challenges to infection prevention strategies in long-term care. Some additional strategies include:
    • Routines are very important for residents with dementia. Establish and maintain infection prevention routines around hand hygiene, social distancing and using a face covering (if tolerated).
      • Residents who are unable to remove their mask independently should NOT wear one.
    • Dedicate personnel to work in memory care only and limit team to essential personnel only.
    • Provide structured activities in residents’ rooms when possible. If activities must take place outside of the room, consider strategies to ensure social distancing, like staggered times.
    • Increase cleaning of high-touch areas, especially hallway banisters, counters, doorknobs, etc.

Advanced Directives

  • Actively engage residents and family members in advanced directives, living wills, provider order for life sustaining treatment (POLST) agreements and other end of life wishes.

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