|§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 observation and facility policy review, it was determined that the facility failed to ensure that staff handled resident equipment in a safe and sanitary manner to prevent the spread of infection for one of 27 residents reviewed (Resident 77).
Review of the facility policy entitled "Equipment and Disinfection Procedure," dated January 2019, revealed that all oxygen therapy supplies were to be bagged and dated when not in use.
Observations on March 14, 2019, at 8:58 a.m., 9:41 a.m., 10:12 a.m., 10:47 a.m., 11:25 a.m., and again March 15, 2019, at 8:45 a.m., revealed that Resident 77's nasal cannula and oxygen tubing was draped over the resident's wheelchair. The cannula and tubing were undated and unbagged.
28 Pa. Code 211.10(d) Resident care policies
28 Pa. Code 211.12(d)(1)(5)Nursing services.
Previously cited 3/23/18, 6/24/17, 4/6/17
| ||Plan of Correction - To be completed: 04/24/2019|
SS = D Infection Prevention & Control (failed to bag and date Oxygen tubing)
1. Re-education provided to staff members involved who failed to follow policy.
2. In-service for all staff on handling of resident equipment in a safe and sanitary manner to prevent the spread of infection.
3. Nursing Administration will audit for compliance and report to QAPI Committee monthly until resolved.
4. Completion by April 24, 2019.