§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 facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for 11 of 12 months (June 2023 - May 2024), and failed to implement enhance barrier precautions for five of five residents (Residents R3, R20, R22, R32, and R61 ) and failed to disinfect equipment, failed to perform hand hygiene between care for one of three residents (Resident R24), and failed to prevent cross contamination during a dressing change for one of three residents (Resident R17).
Findings include:
Review of facility policy "Infection Control Plan" dated 3/27/24, indicated the facility will monitor and identify trends or patterns of infection. To provide strategies to mitigate infection control risks while maintaining the quality of life of its residents.
Review of facility policy "Enhanced Barrier Precautions" dated 3/27/24, indicated enhanced barrier precautions (EBP) are in place for residents with an infection or colonization of a multi-drug resistant organism (MDRO) wounds and/or indwelling medical devices, such as an indwelling catheter, trach/vent, central line, and feeding tube. Gowns and gloves are to be on before entering residents' rooms and used when providing high contact care with a resident who is in EBP.
Review of the facility policy "Cleaning and Disinfection of Resident- Care Items and equipment" dated 3/24/24, indicate resident care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current center for disease control (CDC) recommendations for disinfection and the Occupational Safety and Health Administration (OSHA) bloodborne pathogen standard.
Review of the facility policy "Dressings, Dry/Clean" dated 3/27/24, indicated clean the bedside stand, establish a clean field. Place the clean equipment on the clean field.
Review of the facility's Infection Control documentation for the previous 12 months (June 2023 - May 2024), failed to reveal surveillance for tracking infections for residents for months June 2023 through April 2024.
During an interview on 5/23/24, at 9:35 a.m. Registered Nurse Assessment Coordinator (RNAC) Employee E1 indicated she took over the Infection Control Program last month when former Interim Director of Nursing Employee (DON) E18 left. She produced tracking for the month of May 2024, and indicated this is the documentation that she had.
During an interview on 5/23/24, at 9:45 a.m. the DON confirmed that the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for 11 of 12 months and was unable to produce the tracking records from June 2023 - April 2024.
Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/15/24, indicated admission date of 9/22/2021, with diagnoses of heart failure (heart can't pump blood as well as it should), hypertension (high blood pressure), neurogenic bladder (lack of bladder control).
Review of Resident R3 physician orders dated 5/14/24, indicated foley catheter (indwelling tube in the bladder to drain urine) size sixteen French with 10cc balloon.
Review of physician orders and care plan for R3 failed to indicate EBP relating to the indwelling catheter.
Review of Resident R20's admission record indicated admission date of 9/22/2020, with diagnosis that included end stage renal disease (kidneys can no longer work as they should), diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and hypertension.
Review of Resident R20's current physician orders indicated left upper extremity AV fistula.
Review of Resident R20's physician orders and care plan failed to indicate EBP relating to indwelling medical device.
Review of Resident R22's MDS dated 3/15/24, indicated admission date of 11/3/23, with the diagnoses of End Stage Renal Disease, chronic obstructive pulmonary disease (COPD- a group of diseases that block airflow and make it hard to breathe), and seizures (a person experiences abnormal behaviors, symptoms, and sensations, sometimes including loss of consciousness).
Observation of Resident R22's right chest on 5/20/24, at 9:13 a.m. indicated the presence of a tessio catheter to the right chest.
Review of Resident R22's physician orders and care plan failed to indicate EBP relating to central line.
Review of Resident R32's MDS dated 3/21/24, indicated admission date of 7/25/26, with the diagnoses of End Stage Renal Disease, diabetes mellitus, and chronic kidney disease.
Review of Resident R32's current physician orders indicated right chest hemodialysis catheter.
Review of Resident R32's physician orders and care plan failed to indicate EBP relating to central line.
Review of Resident R61's MDS dated 4/19/24, indicated admission on 1/20/24, with the diagnoses of End Stage Renal Disease, dependence on renal dialysis, and chronic kidney disease.
Review of Resident R61's current physician orders indicated AV shunt left forearm.
Review of Resident R61's physician orders and care plan failed to indicate EBP relating to indwelling medical device.
During an interview on 5/23/24, at 9:30 a.m. the DON confirmed the facility failed to implement enhance barrier precautions for five of five residents (Residents R3, R20, R22, R32, and R61 ).
Review of Resident R24's MDS dated 4/12/24, indicated admission date of 1/10/22, with the diagnosis of diabetes, hyperlipidemia, and depression.
During an observation 5/22/24, at 8:33 a.m. Licensed Practical Nurse (LPN) Employee E7 was completing a blood pressure check prior to medication administration on Resident R24. LPN Employee E7 did not clean off the blood pressure cuff before or after use and also failed to complete hand hygiene before or after medication pass for resident R24.
During an interview 05/22/24, at 09:02 a.m. LPN Employee E7 confirmed the failure to clean reusable resident equipment before and after use and failed to complete hand hygiene.
Review of Resident R17's MDS dated 4/20/24, indicated admission date of 6/11/21, with the diagnosis of atrial fibrillation (abnormal heartbeat), coronary artery disease (limits blood flow in arteries), heart failure (heart can't pump enough blood).
Review of Residents R17's physician orders indicate to apply Medi- honey and calcium alginate (wound treatments) dressing to right outer ankle every morning.
During an observation on 5/22/24, at 9:30 a.m.LPN Employee E7 did not clean off Resident R17's bedside stand prior to placing clean dressings, and failed to clean the bedside stand after completion.
During an interview on 05/22/24, at 09:45 a.m. LPN Employee E7 confirmed the failure to cleanse bedside stand surface before or after dressing change.
28 Pa. Code: 211.10(d) Resident Care Policies.
28 Pa. Code: 211.12(d)(1)(5) Nursing Services.
| | Plan of Correction - To be completed: 07/09/2024
Plan of Correction:
Identified:
Infection control program has been updated to include a system of surveillance to identify possible communicable diseases or infections to meet at least once per month
Barrier precautions policy and procedure was immediately reviewed with staff
Policy and procedure on how to disinfect equipment was immediately reviewed with appropriate staff
Hand hygiene policy and procedure was immediately reviewed with staff
Dressing change policy and procedure was immediately reviewed with staff
No residents that were identified experienced any adverse effects
Education:
Director of Nursing or designee will educate nursing staff on F-880 with a focus on following proper infection control techniques during dressing changes, hand hygiene, disinfecting equipment before and after use, and barrier precautions
Monitor/Audit:
Director of Nursing or designee will conduct audits of the nursing staff to ensure proper procedures are followed in regard to disinfecting equipment, hand hygiene, dressing changes, and barrier precautions weekly for two (2) weeks and then monthly for two (2) months. Two (2) staff members will be reviewed per audit
Audit results will be reviewed at the Quality Assurance and Performance Improvement (QAPI) meeting for review and recommendation.
Anticipated date of compliance: 9 July 2024
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