§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.
§483.80(e) Linens.
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.
|
Observations:
Based on observation, review of facility policy and procedure, and interviews with staff, it was determined that the facility failed to handle and transport linens to prevent the spread of infection on one of two nursing units. (East wing)
Findings include:
Observation at the East Wing of the facility, on March 201, 2024, at 10:07 a.m., revealed that a Nurse Aide, Employee E6, was transporting clean linen for the use of residents by holding the linens letting it to touch the Nurse aide's uniform.
Interviewed conducted with Nurse aide, Employee E6, at the timed of the interview, it was confirmed that the linens should have been transported without letting it touch the employee's clothing to prevent contamination and to maintain infection control practices.
28 Pa Code 201.14(a) Responsibility of licensee
28 Pa Code 211.12 (d)(1)(5) Nursing services
| | Plan of Correction - To be completed: 04/11/2024
This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the Department's inspection report.
1. No specific residents were identified or noted as affected. Employee E6 was re-educated regarding proper transportation of linens per facility policy by the Staff Educator.
2. An audit was completed to validate CNA staff were transporting linen per facility policy which includes not holding linen up against staff uniform to prevent contamination by the Staff Educator. No variances were identified.
3. Nursing staff will be re-educated by Director of Nursing/Designee on handling and transporting linen per facility policy which includes not holding linen against staff uniform to prevent contamination and the spread of infection.
4. The Director of Nursing/Designee will complete an audit by observing 10 staff members per week for 4 weeks then monthly for 2 months to validate that CNA staff are handling and transporting linen in a manner that prevents the spread of infection. Audit findings will be submitted to the Quality Assurance Performance Improvement committee for further review and recommendations as needed. Further audit frequency will be determined based on the outcome of previously completed audit findings.
|
|
