§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.
|
Observations:
Based on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to maintain infection control practices to prevent the potential for cross contamination while during wound care and personal hygiene care for two of four residents (Resident R1 and R2).
Findings include:
Review of the facility policy " Wound Care " dated 6/11/25, indicated wash and dry hands thoroughly. Put on clean gloves, loosen tape and remove dressing. Pull glove over dressing and discard into appropriate receptacle. Wash and dry hands thoroughly.
Review of the facility policy " Handwashing/Hand Hygiene" dated 6/11/25, indicated use alcohol-based hand rub containing at least 62% alcohol and/or soap and water before handling clean or soiled dressings, gauze pads, etc.; After handling used dressings, contaminated equipment, etc.; The use of gloves does not replace hand washing/hand hygiene. "
Review of facility policy " Enhanced Barrier Precautions " dated 4/1/26, indicated enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDRO) to residents. EBPs are indicated for residents with wounds and/or indwelling medical devices (instruments or implants placed inside the body to remain for extended time to support, monitor, or treat medical conditions). Personal protective equipment (PPE) of gown and gloves are used during high-contact resident care activities, including dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care, or wound care.
Observation of signage posted on Resident R1 and R2 room door indicated the need for enhanced barrier precautions. No signage was present related to contact precautions.
Review of the clinical record revealed Resident R1 was admitted to the facility on 6/24/26.
Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 6/28/26, included diagnoses of a hip fracture and aftercare needed after orthopedic surgery. Review of Section M: Skin Conditions indicated Resident R1 has surgical wounds.
Review of Resident R1 ' s baseline care plan initiated 6/24/26, failed to reveal a plan of care developed for enhanced barrier precautions.
Review of Resident R1 ' s comprehensive care plan in process on 7/5/26, failed to reveal a plan of care developed for enhanced barrier precautions.
Review of a physician ' s order dated 6/25/26, indicated " leave dressing in place for 5-7 days and then remove / may be changed as need for drainage, soilage, or saturation. One time a day for wounds. "
Review of the clinical record revealed Resident R2 was admitted to the facility on 6/22/26.
Review of the MDS dated 6/28/26, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), osteomyelitis (inflammation of bone or bone marrow, usually due to infection), and resistance to multiple antibiotics. Review of Section M: Skin Conditions indicated Resident R2 has diabetic foot ulcers.
Review of Resident R2 ' s baseline care plan initiated 6/22/26, failed to reveal a plan of care developed for enhanced barrier precautions.
Review of Resident R2 ' s comprehensive care plan in process on 7/5/26, revealed that Resident R2 required contact precautions for MRSA (Methicillin-resistant Staphylococcus aureus, a type of "staph" bacterium that has developed resistance to many common antibiotics, including methicillin, penicillin, and amoxicillin) of a wound.
Review of a physician ' s order dated 6/24/26, indicated " Resident placed on contact precautions related to (mrsa) wound. "
Review of a physician ' s order dated 6/22/26, indicated " Location (right foot) Clean wound with NSS (normal saline solution), pat dry, apply calcium alginate (highly absorptive, non-occlusive dressings made of soft, non-woven calcium alginate fibers), cover with 4x4 gauze, wrap with Kerlix (absorbent rolled bandage) and then ace wrap. "
During an observation of a wound dressing change on 7/5/26, at approximately 2:50 p.m. the following was observed:
-Registered Nurses (RN) Employees E1 provided wound care without wearing a gown.
-RN Employee E1 completed Resident R1 ' s dressing change on his left upper thigh surgical wounds while Resident R1 was on a bedpan.
-No clean field was present on the bed.
-RN Employee E1 removed Resident R1 ' s soiled dressings then reapplied clean dressings without changing gloves or performing hand hygiene.
During an observation on 7/5/26, at approximately 2:55 Nurse Aide (NA) Employee E2 removed the bed pan and cleaned the remaining stool from Resident R1 without wearing a gown.
During an observation of a wound dressing change on 7/5/26, at approximately 2:55 p.m. the following was observed:
-RN Employees E1 provided wound care without wearing a gown.
-No clean field was present on the bed, under Resident R2 ' s foot.
-RN Employee E1 removed Resident R2 ' s dressing. Dressing was visibly soiled with drainage.
-RN Employee E1 placed the soiled dressings on Resident R1 ' s dresser, on an empty dressing wrapper.
-RN Employee E1 cleaned Resident R2 ' s wound with wound cleanser (order was for NSS), without changing gloves or performing hand hygiene.
-RN Employee E1 looked through the clean dressing supplies items on the dresser top.
-RN Employee E1 removed her right glove, and exited the room. RN Employee E1 was observed to be looking through the drawers of the treatment care just outside Resident R2 ' s room door.
-RN Employee E1 returned to the room, and placed the clean supplies on the dresser top next to the soiled dressing. Closer observation at this time revealed the clean supplies to be touching the soiled dressing.
-RN Employee E1 donned a clean glove on her right hand, without performing hand hygiene.
-RN Employee E1 reapplied a clean dressing.
During an interview on 7/5/26, at approximately 3:15 p.m. the Nursing Home Administrator confirmed the facility failed to maintain infection control practices to prevent the potential for cross contamination while during wound care and personal hygiene care for two of four residents.
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(b)(1)(e)(1) Management.
28 Pa. Code: 201.20(c) Staff development.
28 Pa. Code: 211.10(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.
| | Plan of Correction - To be completed: 08/04/2026
The facility will maintain infection control practices to prevent the potential for cross contamination during wound care and personal hygiene to residents. The facility cannot retroactively correct the concern identified for residents R1 and R2.
Resident R2 wound was evaluated and clean dressing applied using appropriate infection control practices immediately once brought to the facilities attention during survey.
A house audit will be completed to identify residents indicated for enhanced barrier precaution (EBP) and contact precautions to validate proper signage and personal protective equipment is available (PPE).
The Director of Nursing (DON) or designee will re-educate nursing staff, including new hires and agency on the facility policy and procedures for infection control that prevent the potential for cross-contamination during wound care and personal hygiene. Education will include EBP, PPE and hand hygiene.
The DON or designee will complete 3 wound observations and 3 personal hygiene observations weekly for 4 weeks to validate nursing staff is maintaining infection control practices to prevent the potential for cross contamination.
The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.
|
|
