|§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 review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that hand hygiene procedures were followed by staff involved in direct resident contact for one of five residents reviewed (Resident 1).
The facility's policy regarding hand washing, dated March 5, 2019, indicated that hands were to be washed before applying and after removing gloves, and when visibly soiled.
A comprehensive significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated February 12, 2020, indicated that the resident was always incontinent of urine and bowel and required the extensive assistance of two staff for hygeine.
Observations of Resident 1 on March 4, 2020, at 8:30 a.m. revealed that Nurse Aides 1 and 2 assisted the resident to use the toilet. Afterward, Nurse Aide 1 performed hygeine care and her glove was visibly soiled. The nurse aide wiped her glove off with a cleansing wipe and then proceeded to apply protective cream to the resident's buttocks with the same glove on. She then removed her gloves, and without washing her hands she applied a clean incontinent brief and the resident's clothing.
Interview with Nurse Aide 1 on March 4, 2020, at 8:46 a.m. confirmed that she should have removed her gloves and washed her hands after providing hygiene care to Resident 1 and before applying the ointment.
Interview with the Assistant Director of Nursing on March 4, 2020, at 11:56 a.m. confirmed that after providing hygeine care, staff were to remove their gloves and wash their hands before providing further care.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
| ||Plan of Correction - To be completed: 04/21/2020|
Resident 1 suffered no ill effects
Immediate one to one education was done with the certified nurses aide.
All residents who receive incontinent care have the potential to be affected by this deficient practice.
A whole house audit was completed on certified nurses aides to ensure that after providing hygiene care, staff were to remove their gloves and wash their hands before providing further care.
Re-education was provided to certified nurses aides including agency staff on the need to remove their gloves and wash their hands before providing further care.
The Director of Nursing/Designee will perform random audits to ensure staff is removing their gloves and washing their hands before providing further care.
These audits will be performed bi-weekly times 4 weeks and then monthly times 3 months or until substantial compliance. Results from audits will be reviewed by Quality Assurance Performance Improvement Committee at its regularly scheduled meeting times 3 for results, areas of improvement and/or continuation of audits.