|§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, review of clinical records and facility policies and staff interview, it was determined that the facility failed to prevent the potential for cross contamination during a dressing change for one of 21 residents (Resident R18).
Resident R18's admission record revealed a date of 9/08/17, with diagnoses that included high blood pressure, diabetes, coronary artery disease, chronic obstructive pulmonary disease (inflammatory lung disease that causes obstructed airflow from the lungs), and adult failure to thrive (weight loss of more than 5%, decreased appetite, poor nutrition, and physical inactivity, often associated with dehydration, depression, immune dysfunction, and low cholesterol).
A facility policy entitled "Hand Washing- Infection Control" dated 9/11/18, indicated that the use of gloves does not replace the need for hand cleaning, and that hand hygiene should be performed after removing gloves, before handling an invasive device regardless of whether or not gloves are used, after contact with body fluids or excretions, non-intact skin and/or wound dressings.
Observation on 9/10/19, at 10:13 a.m. revealed that the wound Certified Registered Nurse Practitioner (CRNP) washed his/her hands, applied gloves and cleansed a wound on Resident R18's right great toe, after which he/she applied skin prep wipes to the wound on the right great toe. The CRNP changed his/her gloves without washing his/her hands and began to clean the wound on Resident R18's coccyx/sacral area with normal saline solution and measure the wound while touching the wound and surrounding tissues. The CRNP began to pack the wound with a clean dressing (gauze roll soaked with normal saline) without changing his/her contaminated gloves and/or washing his/her hands. He/she applied skin prep wipes around the wound and placed a foam dressing over the saline soaked gauze inside the wound using the same contaminated gloves.
28 Pa. Code 211.10(c)(d) Resident Care Policies
28 Pa. Code 211.12 (d)(2) Nursing Services
28 Pa. Code 211.12(d)(1)(5) Nursing Services
Previously cited 10/15/18
| ||Plan of Correction - To be completed: 10/15/2019|
Resident 18 had no adverse effects from the dressing change.
Residents that have wounds that require dressing changes have the potential to be affected. Initial observation of dressing change was completed.
Practitioners who perform dressing changes will be re-educated on proper procedure to prevent infection and cross contamination. A screen of dressing changes was completed to determine residents with dressing ordered.
The DON or designee will be responsible for ongoing compliance monitoring. Audits of two dressing changes (infection control) will be conducted five times per week for two weeks, weekly for two weeks, and monthly for two months. Results of the audits will be reported to the Quality Assurance Performance Improvement committee monthly for two months then as directed by the QAPI committee.