|§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 observation of medication administration, staff interview and review of facility's policy and procedures, it was determined that the facility failed to ensure proper hand washing during the administration of medications for four of four residents observed. (Residents R 155, R 217, R 219, R 221)
Reviewed the facility policy and procedure title "Hand Hygiene" revised 03/2019 revealed "All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents and visitors. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap may also be utilized for washing/hand hygiene. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.
Observations conducted on September 11, 2019 at 8:27 a.m. duruing medication administration revealed licensed nursing staff, Employee E4 removed Resident R217's meal tray off the bedside table and place it in the food truck.
Licensed nursing staff, Employee E4 then returned to the medicine cart, documented the medicine given to Resident 217 then removed the blood pressure cuff from medicine cart and took Resident R219 blood pressure. After obtaining the blood pressure licensed nursing staff, Employee E4 did not wash hands or use hand sanitizer and proceeded to pour a medication for Resident R219.
The facility failed to ensure that the staff adhere to infection control procedures related to hand hygiene.
28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 08/12/19, 03/12/19, 03/21/19, 08/24/18
28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 03/12/19, 03/21/19, 08/24/18
| ||Plan of Correction - To be completed: 10/22/2019|
Residents R155, R217, and R221 were Monitored closely for signs and symptoms of infection that may have been spread through the administration of medications by a nurse who failed to use the proper hand hygiene during her medication pass. The nurse who was observed administering medications to residents: R155, R217, and R221 without following the hand hygiene procedure received one to one training on proper hand hygiene with positive return demonstration.
Facility did not identify any further occurrences of the deficient practice that was observed during the medication pass including residents R155, R217, and R221.
Facility will be educating staff on the Hand Hygiene policy. All participants in the in-service education will return a positive demonstration of proper hand washing technique. Infection control preventionist or designee will monitor had hygiene routinely throughout the facility.
Random observations by the ADON and or designee will be conducted weekly X four weeks to ensure that the proper hand hygiene procedures are being followed. Results of the random audits will be discussed through QAPI to identify if there are any trends and to determine if the need to continue the random audits exists.