|§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 facility policy, observation, and staff interview, it was determined that the facility failed to 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 on two of four nursing units. (Heritage nursing unit, West nursing unit)
Review of the facility's policy entitled "Support Services, Laundry Services and Linen Handling Practices", dated January 1, 2019, revealed that clean linen was to be covered for protection during transport and clean linen was to be stored in a protected area until distributed for use.
Observation of the Heritage nursing unit on March 10, 2019, between 9:06 a.m. and 11:00 a.m., revealed two uncovered linen carts, one on the low hall and one on the high hall.
Observation of the Heritage nursing unit on March 11, 2019, at 10:25 a.m., revealed an unattended, uncovered linen cart on the low hall.
Observation during the medication pass on the Heritage nursing unit low hall, on March 10, 2019, between 9:06 a.m., and 10:00 a.m., revealed an opened, uncovered container of applesauce on top of the medication cart.
Observation of Resident 92's room on March 10, 2019, at 9:30 a.m., 11:00 a.m., and 1:00 p.m., revealed an oxygen concentrator with tubing and canula draped over the concentrator that was not bagged, labeled, or dated.
Observation of West nursing unit dining room on March 11, 2019, at 9:35 a.m., revealed an unattended, blue-colored ice cooler containing partially melted ice and large styro-foam cup stored inside.
Observation of the West nursing unit dining room on March 11, 2019, at 11:14 a.m., revealed an unattended red-colored ice cooler with a scoop stored inside and a used resident meal tray stored below the ice cooler. A second observation on the same day at 2:01 p.m., revealed the same used meal tray had not been removed from the ice cart.
28 Pa. Code 211.10(d) Resident care policies.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
28 Pa. Code 201.18(b)(1) Management.
| ||Plan of Correction - To be completed: 05/07/2019|
The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein.
1. No residents were directly impacted by this deficient practice.
2. New admissions and current residents have the potential to be affected by the deficient practice. Utilizing the Nursing Services QAPI audit tool, a comprehensive audit was
completed for compliance
3. To ensure the deficient practice does not recur, the nursing staff will be educated by the NHA/ designee on Focus on F Tag 880, Infection Prevention & Control on or before the date of compliance
4. Utilizing the Nursing Service QAPI audit tool the Administrator / designee will audit 4 observations weekly for 4 weeks for compliance.
5. The building will allege compliance on May 7, 2019