§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.
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Observations:
Based on review of facility policies, review of Centers for Disease Control (CDC) guidelines for Legionella (bacterium that causes Legionnaires Disease found in pipes and heating systems) Control, the facility's infection control tracking logs for water management and staff interview, it was determined that the facility failed to implement a comprehensive program for water management to monitor the potential development and spread of Legionella within the facility, failed to exercise proper infection control techniques and dispose of contaminated PPE (personal protective equipment) during a dressing change to prevent the potential of spread of infection for one of three residents (Resident R59).
Review of the facility "Legionella Policy-Environmental" reviewed 12/13/23, indicated that the facility will implement control measures to reduce the potential for the growth and spread of Legionella by quarterly testing of chlorine levels. The facility indicated that the "Weekly Water Temperature Inspection" logs are used to track the testing of the water temperatures and the chlorine levels. The log indicated quarterly chlorine levels will be a minimum residual level 0.5 mg/L (milligram per liter).
During an observation of the facility provided "Weekly Water Temperature/Inspection" forms dated October 2023 through February 2024, indicated in November "less than" and an unidentifiable word. The February 2024 column indicated a date of 2/2/24, with no documented chlorine level.
During an interview on 2/13/24, at 10:25 a.m., the Nursing Home Administrator and Maintenance Director confirmed that the facility failed to implement a comprehensive program for water management to monitor the potential development and spread of Legionella within the facility.
During an interview on 2/14/23, at 9:25 a.m., Licensed Practical Nurse (LPN) Employee E1 indicated that Resident R59 was in enhanced precautions (staff to use PPE during dressing changes) as indicated by a sign above the bed.
During an observation on 2/14/24, at 9:25 a.m., of Resident R59's wound care revealed the following:
LPN Employee E1 removed scissors from her scrub pocket and cut off Resident R59's left foot dressing without first cleaning the scissors.
LPN Employee E1 removed soiled gloves multiple times and placed them in the garbage can below the sink utilized by both residents in the room.
LPN and the Nurse Aide (NA) Employee E4 removed their gowns, masks and gloves after treatment and placed them in the same garbage can and the bag was not removed prior to leaving the room.
During an interview on 2/14/24, at 10:25 a.m., LPN Employee E1 confirmed that the facility failed to exercise proper infection control techniques and dispose of contaminated PPE during a dressing change to prevent the potential of spread of infection for Resident R59.
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(b)(1)(e)(1) Management.
28 Pa. Code: 201.20(c) Staff Development.
28 Pa. Code: 211.10(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.
| | Plan of Correction - To be completed: 03/25/2024
On 2/14/24, Environmental Services Supervisor retested the chlorine levels and recorded 1.0 mg/L in both areas tested (B hall and C hall), and the numeric level was recorded on the "Weekly Water Temperature form". The Environmental Services Supervisor and Maintenance Staff will be educated by the corporate project Manager or designee in March 2024 on the appropriate procedure to test, record, and respond to chlorine levels per the facility's Water Management Program. A new chlorine tester will be purchased to ensure clearer numeric readings during facility chlorine testing. The Environmental Services Supervisor or designee will audit chlorine levels in the facility through use of the new tester weekly for four weeks, monthly for three months, and then quarterly thereafter. Results of audits will be reviewed at Quarterly QAPI meetings.
LPN Employee E1 and Nurse Aide Employee E4 were immediately educated on proper infection control techniques and disposal of contaminated PPE. The Director of Nursing or designee will provide education to nursing staff members on Feb 28,2024 on proper infection control techniques and disposal of contaminated PPE. In addition, Infection Preventionist or designee will provide all direct care staff education on infection control in regards to PPE donning, doffing, and disposal during March 2024 inservices. Audits will be performed by Infection Preventionist or designee via conducting rounds throughout the facility on infection control techniques and disposal of PPE weekly for one month, then monthly for three months. Findings of the audits will be forwarded to the Quality Assessment Process Improvement Committee for review and recommendations.
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