|§483.80 Infection Control|
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:
§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards;
§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.
§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.
§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were used during resident care for four of 42 residents reviewed (Residents 13, 16, 106, 212).
The facility's policy regarding incontinent care, dated November 1, 2018, indicated that staff were to always perform hand hygiene after gloves were removed and prior to providing additional care to residents.
The facility's hand hygiene policy, dated November 1, 2018, revealed that whether or not gloves were worn, hand hygiene was to be performed after contact with blood and body fluids, mucous membranes or secretions.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated November 2, 2018, revealed that the resident was cognitively intact, required extensive assistance for hygiene, was totally dependent on staff for bathing, and was always incontinent of bowel and bladder.
Observations of Resident 13 on February 4, 2019, at 11:40 a.m. revealed that the resident had been incontinent of urine and with gloves on, Licensed Practical Nurse 9 cleaned the resident's perineal area (in and around the genitals). After cleaning the resident, Licensed Practical Nurse 9 removed her gloves, and without washing her hands, she applied new gloves and continued care. Interview with Licensed Practical Nurse 9 at that time confirmed that she did not wash her hands before putting on new gloves and she should have.
Interview with the Director of Nursing on February 5, 2019, at 1:36 p.m. confirmed that staff are to wash their hands after taking their used gloves off and before putting on clean gloves.
An annual MDS assessment for Resident 16, dated November 6, 2018, indicated that the resident required the extensive assistance of two persons for daily care tasks, had diagnoses that included obstructive uropathy (when urine cannot drain through the urinary tract), and had an indwelling urinary catheter (tube inserted and held in the bladder to drain urine). Physician's orders dated May 23, 2018, indicated that the resident had a suprapubic catheter (tube surgically inserted into the bladder through an opening in the abdomen).
Observations on February 4, 2019, at 10:45 a.m. revealed that a closed urinary drainage bag, that was not connected to Resident 16's suprapubic urinary catheter, was hanging on the top bedrail of the resident's bed, and there was no protective cap on the tip (the part that gets connected to the resident's catheter).
Interview with Licensed Practical Nurse 3 on February 4, 2019, at 10:45 a.m. confirmed that Resident 16's urinary drainage bag was disconnected and hanging on the resident's bedrail without a protective cap on the tip.
A quarterly MDS assessment for Resident 106, dated January 4, 2019, indicated that the resident was alert and oriented, dependent on limited-to-extensive assistance of one to two persons for daily care, had diagnoses that included urinary retention (residual urine retained in the bladder), and had an indwelling urinary catheter.
Observations on February 4, 2019, at 9:40 a.m. revealed that the resident's closed drainage urinary catheter bag was on the floor with the port side (tube that is used to empty the urine from the bag) was in direct contact with a fall mat (device placed on the floor next to the bed to prevent injuries from falls).
Interview with Registered Nurse 1 on February 4, 2019, at 9:45 a.m. confirmed that Resident 106's catheter bag was on the floor, should not have been, and should have been covered with a dignity bag for privacy.
The facility's policy regarding aerosol nebulizer therapy (turns breathing medication into a mist that can be inhaled into the lunges), dated May 15, 2018, indicated that cleaning and maintenance of the nebulizer machine would be completed following the facility's infection control practices.
A diagnosis record for Resident 212, dated January 2, 2019, revealed that the resident had diagnoses that included chronic obstructive pulmonary disease (COPD - progressive lung disorder that makes it difficult to breathe). Physician's orders, dated January 31, 2019, included an order for the resident to receive one vial of Ipratropium-Albuterol Solution 0.5-2.5 (3) milligrams/3 milliliters (used to treat COPD) via nebulizer, inhale orally two times a day for shortness of breath/wheezing, and 1 vial inhale orally every six hours as needed for shortness of breath.
Observations of Resident 212's nebulizer equipment on February 4, 2019, at 11:48 a.m. and 4:08 p.m. revealed that the nebulizer mask was lying face down in direct contact with the bedside stand and there was a plastic bag bedside it labeled February 3, 2019.
Interview with Registered Nurse 13 (the facility's infection control nurse) on February 4, 2019, at 2:59 p.m. revealed that after a nebulizer treatment was provided, the mask was to be washed, dried with a paper towel, and then placed into the bag. She confirmed that Resident 212's mask should not have been lying on the bedside stand.
42 CFR 483.80(a)(1)(2)(4)(e)(f) Infection Prevention and Control.
Previously cited 3/23/18.
28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 12/6/18, 8/13/18, 3/23/18.
28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 12/6/18, 8/13/18, 7/10/18, 3/23/18.
| ||Plan of Correction - To be completed: 03/22/2019|
The following is submitted for plan of correction purposes only and should not be construed as an admission.
Resident 13 continues to reside at the facility. She receives extensive assistance for hygiene activities in a manner that promotes and maintains infection prevention and control practices.
Licensed Practical Nurse 9 has been re-educated on facility hand hygiene policy, policy regarding incontinence care, and has successfully completed hand hygiene competency.
The nursing staff will be educated on the facility hand hygiene policy, facility policy regarding incontinence care, and federal regulation 880. Nursing staff will complete hand hygiene competencies with the Infection Control Coordinator/designee.
The Infection Control Coordinator/designee will audit staff members providing assistance to residents requiring assistance with incontinence care to ensure infection prevention and hand hygiene practices are maintained throughout the incontinence care. These audits will be completed on 5 residents daily for one week, weekly for two weeks, monthly for two months, and randomly thereafter. Results of these audits will be reviewed in the facility Quality Assurance meeting for further recommendations for continued compliance.
Resident 16 and resident 106 continue to reside at the facility. The Resident's urinary catheters and their drainage system are maintained in a manner that promotes and maintains infection prevention and control practices.
The Infection Control Coordinator/Designee will audit all residents with urinary catheters to ensure indwelling catheter positioning and infection control and prevention practices are maintained. These audits will be completed daily for one week, weekly for two weeks, monthly for two months, and randomly thereafter. Results of these audits will be reviewed in the facility Quality Assurance meeting for further recommendations for continued compliance.
Checking indwelling urinary catheter systems for proper positioning and covering will become part of resident rounds and will be done by both licensed and non-licensed staff. Any needed corrections will be completed immediately.
Resident 212 continues to reside at the facility and her nebulizer equipment is maintained in a manner that promotes and maintains infection prevention and control practices.
Checking respiratory equipment for proper positioning and covering will become part of resident rounds and will be done by both licensed and non-licensed staff. Any needed corrections will be completed immediately.
The Infection Control Coordinator/designee will audit residents receiving nebulizer and or respiratory therapy to ensure proper placement/covering of equipment and infection control and prevention practices are maintained. These audits will be completed on 5 residents daily for one week, weekly for two weeks, monthly for two months, and randomly thereafter. Results of these audits will be reviewed in the facility Quality Assurance meeting for further recommendations for continued compliance.