|§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 clinical record reviews, observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were performed during care for one of four residents reviewed (Resident 3).
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated July 12, 2019, indicated that the resident was cognitively impaired and required extensive assistance for personal hygiene and bathing.
Observations on September 24, 2019, at 7:10 p.m. revealed that Nurse Aides 1 and 2 performed evening care for Resident 3 and washed the resident's perineum (the area around the genitals) then his buttocks while wearing the same gloves and with the same washcloth.
Interview with Nurse Aide 2 on September 24, 2019, at 7:24 p.m. confirmed that she should have changed her gloves after washing Resident 3's perineum and also confirmed that she should have used a clean washcloth to clean the resident's buttocks.
Interview with the Director of Nursing on September 24, 2019, at 8:00 p.m. confirmed that staff should have changed her gloves after cleaning Resident 3's perineum and should have used a new washcloth to clean his buttocks.
28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 8/7/19, 4/25/19, 3/14/19.
| ||Plan of Correction - To be completed: 11/12/2019|
Immediate corrective action was taken for resident 3 to educate the staff with verbal que to repeat incontinence care on September 24, 2019.
In order to protect residents in similar situations re-education will be provided to all current nurse aids, agency nurse aids and new staff team member aids on the proper steps to complete incontinence care and proper supplies needed. In addition to education certified nurse aids will be audited randomly and return demonstration will be provided.
An audit will be created that certified nurse's aides will be evaluated on performing proper incontinence care to random residents. The audit will include the proper steps and when to change gloves and use different wash clothes.
The Director of Nursing or Designee will be responsible to monitor audits. This will ensure the transfers are handled according to plan of care. The flow sheet will be monitored daily for one week, twice weekly for 4 weeks and then weekly for 2 months