§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 review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed while providing medications to the residents.
Findings include:
The facility's policy regarding infection control, dated June 28, 2019, revealed that staff were to follow established infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. The facility's handwashing/hand hygiene policy, dated June 28, 2019, revealed that an alcohol-based hand rub or soap and water should be used before preparing or handling medications, and hand hygiene was to be completed after removing gloves.
Observations during medication administration on December 10, 2019, from 11:59 a.m. to 12:21 p.m. revealed that Licensed Practical Nurse 2 prepared and administered oral medications and an insulin injection to several residents, and she did not wash her hands or use hand gel between residents.
Interview with Licensed Practical Nurse 2 on December 10, 2019 at 12:26 p.m. revealed that she forgot to wash her hands between residents and that she should have.
Observations during medication administration on December 10, 2019, at 12:39 p.m. revealed that Licensed Practical Nurse 3 did not wash her hands or use hand gel prior to applying gloves and administering eye drops to a resident. Observations of Licensed Practical Nurse 3 on December 10, 2019, at 12:52 p.m. revealed that the nurse washed her hands, dried her hands with a clean towel, and then turned the dirty faucet off with her clean hand instead of with a paper towel.
Interview with Licensed Practical Nurse 3 on December 10, 2019, at 1:05 p.m. revealed that she should have used a towel to turn the faucet off and not her clean hand.
Interview with the Director of Nursing on December 11, 2019, at 2:40 p.m. confirmed that staff are to wash their hands or use sanitizing hand gel between residents while administering medications, and that they should never touch the faucet with their clean hands.
28 Pa. Code 211.12(d)(1) Nursing services.
28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 9/30/19, 6/13/19.
| | Plan of Correction - To be completed: 01/27/2020
1. What corrective action(s) will be accomplished for those residents found to have been affected by the finding;
No resident was identified to be affected by the finding.
2. How will you identify other residents having the potential to be affected by the same finding and what corrective action will be taken;
All residents have the potential to be affected by the finding. Licensed (Registered Nurses and Licensed Practical Nurses) staff will be re-educated on hand washing and alcohol gel use related to medication administration. Any licensed nursing agency staff scheduled will be re-educated prior to the start of their next scheduled shift.
3. What measures will be put into place or what system changes will you make to ensure the finding does not recur;
The Director of Nursing/designee will conduct 4 random medication pass audits/observations weekly to ensure proper procedure. Random audits/observations will continue until 3 consecutive months of compliance is achieved.
4. How the corrective action will be monitored to ensure that the finding will not recur; i.e., what quality assurance programs will be established;
The Director of Nursing/designee will present the results of the audits to the Quality Assurance Performance Improvement Committee during monthly Quality Assurance Performance Improvement Committee Meetings to ensure completion and compliance.
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