§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 §483.71 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 the observations and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to the care of urinary catheters and respiratory care equipment for four of 35 residents reviewed.
Findings Include:
Observation of Resident R135 on November 19, 2024, at 10:32 a.m., revealed that the resident had a urinary catheter. Further observation revealed that the catheter bag was on the floor.
Observation of Resident R17 on November 19, 2024, at 10:25 a.m., revealed that resident's oxygen tubing which was connected to oxygen concentrator was lying on the floor without any bag.
Observation of Resident R61 on November 19, 2024, at 10:28 a.m., revealed that resident's urinary catheter bag and the tubing was on the floor mats, it was observed that the Nurse Aide who was providing care to the resident was stepping on the floor mat while the catheter tubing and bag was on it. Further observation revealed that there was nebulizer machine and tubing on windowsill. The nebulizer mask and tubing were not bagged, and it was directly placed on the windowsill.
Observation of Resident R90 on November 19, 2024, at 10:20 a.m., revealed that resident had tracheostomy to assist with breathing. The tracheostomy blue corrugated tubing with fluid collection bag was placed in a trash container while the resident was actively using the tracheostomy.
A follow up tour with Employee E15, Unit Manager on November 19, 2024, at 11:00 a.m. confirmed the above observations. 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: 01/13/2025
R61 and R 135 catheter bags replaced Catheter bags for R61and R135 secured to bed frame
Resident R17 oxygen tubing replaced and oxygen canula bag attached to concentrator for storage of oxygen tubing R61 Nebulizer tubing removed from window seal discarded and replaced with a new one stored in a bag at bedside R90 corrugated tubing with fluid collection bag replaced and trash container removed Initial audit of residents with foley catheter was completed to ensure placement that catheter bags are not touching the floor, oxygen tubing, tracheostomy tubing and nebulizer storage was completed Initial audit of residents on oxygen tubing, nebulizer tubing and tracheostomy tubing completed to ensure that tubing is not on the floor or in trash container or stored on window seal and proper storing of tubing's Staff educator or designee will complete infection control education about catheter bag placement, Oxygen tubing, nebulizer tubing storage and tracheostomy corrugated tubing to all nursing staff by 12/31/2024 Infection control nurse/designee will complete weekly audit of catheter placement, oxygen tubing/nebulizer tubing storage and Tracheostomy corrugated tube placement. Audit will be completed weekly x4 weeks, then monthly x 3 months Results of audit will be presented at the Monthly QAPI meeting until substantial compliance is achieved.
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