|§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 observations, staff interviews and review of the facility policy, it was determined that the facility did not maintain acceptable standards of infection control practice related to handwashing technique during wound care for one of one residents observed during wound care (Resident R144).
Review of the facility policy "Handwashing and Hand Hygiene" dated October 31, 2013, revealed that the policy stated that the purpose is to prevent cross contamination. To remove gross soil and to decontaminate hands. The procedure specified: wet hands, apply soap, rub hands together covering all surfaces of the hands and fingers for 20 seconds, rinse hands with water, dry thoroughly with paper towel and use towel to turn off faucet. Indications for Handwashing/Hygiene: After removing gloves.
Observation on March 4, 2019, at 1:04 p.m. prior to performing Resident R144's wound care, Employee E16, Licensed Practical Nurse-LPN, washed her hands for approximately 15 seconds then donned two pairs of gloves. During wound care, Employee E16 used a pair of scissors from the treatment cart to cut gauze dressing to the size of the wound. The scissors were not cleaned with a disinfectant wipe before or after the procedure. After the procedure, Employee E16 did not wash her hands.
Interview with Employee E3, Infection Preventionist on March 7, 2019, at approximately 10:15 a.m. revealed that staff were inserviced (educated) to wash hands with soap and water for 20 seconds.
The facility failed to implement adequate standard infection control procedures related to hand hygiene during wound care.
28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 07/25/18, 02/01/17
28 Pa. Code 201.18(b)(1)(3)(e)(1) Management
28 Pa. Code 211.10(d) Resident care policies
28 Pa. Code 211.12(c)(d)(2) Nursing services
28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 01/04/18, 02/01/17
28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 02/01/17
| ||Plan of Correction - To be completed: 04/16/2019|
Infection Prevention & Control
1. Employee E16 was re-educated on hand hygiene and proper procedure for wound treatment/ disinfecting scissors.
2. All nursing staff received in-servicing on hand hygiene and proper procedure for wound treatment/disinfecting scissors.
3. 2 random audits will be done weekly by Staff Educator to make sure solutions are sustained.
4. Results of audits will be reported at monthly QAPI meeting by Staff Educator to make sure solutions are sustained. The need for continued audits will be reassessed at that time for compliance.