|§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 facility policy, review of clinical records, and staff interview, it was determined that the facility failed to maintain effective infection control prevention practices for hand hygiene during wound treatment to prevent spread of infection for one of one wound treatment observed (Resident R50).
Review of facility policy "Hand Hygiene" revealed hand hygiene is the most important infection control measure to prevent illness in skilled nursing facilities. Hands should be sanitized or washed before and after direct resident contact, before and after each procedure or task, and after contact with excretions (any bodily fluid).
Review of Resident R50's clinical record revealed the resident developed a new area to her right gluteal fold on June 19, 2022.
Observations on August 4, 2022, at 9:45 a.m. revealed Registered Nurse, Employee E3, completed Resident R50's wound treatment. Observations during wound care revealed Registered Nurse, Employee E3 removed a soiled dressing from the gluteal wound and cleaned the barrier cream from the wound. Upon completion of the task, Registered Nurse, Employee E3 put on a pair of new gloves and did not use hand sanitizer or soap and water after handling the soiled dressing and continued to apply a clean dressing to the resident's wound.
Upon completion of wound care, findings were reviewed and confirmed with Registered Nurse, Employee E3.
28 Pa. Code 211.10(c) Resident care policies
28 Pa. Code 211.12(d)(1) Nursing services
| ||Plan of Correction - To be completed: 09/15/2022|
A. Resident R50 did not have ill effects from deficient practice.
B. Employee E3 was reeducated on the Hand Hygiene policy and its role in wound care.
C. Licensed staff were reeducated on the "Hand Hygiene" policy with a focus on wound care and dressing changes.
D. ADON will conduct an audit of 5 random staff members weekly X4 and then monthly X2 to ensure hand hygiene is performed appropriately during wound care dressing changes. Audit findings will be forwarded monthly to the Quality Assurance Process Improvement team for review and recommendations, to include ensuring successful evaluation
DON/designee to conduct an audit of the ADON X2 weekly and then X2 monthly to ensure ongoing ADON compliance with hand hygiene during wound care. Audit findings will be forwarded monthly to the Quality Assurance Process Improvement team for review and recommendations, to include ensuring successful evaluation.