|§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, policy review and staff interview, it was determined that the facility failed to maintain an infection control program designed to prevent the development and transmission of disease and infection for one of four residents observed (Resident 4).
Review of facility policy, "Isolation - Initiating Transmission-Based Precautions," revealed, "Contact Precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment." The policy goes on to state that while caring for a resident staff will wear gloves(clean, non-sterile) when entering a room and will wear a disposable gown upon entering the room.
During an interview with a Nurse Aide on September 25, 2019 at 9:30 AM it was revealed she would use disposable gown to provide care.
Surveyor observation on September 25, 2019, at 12:00 PM, revealed a personal protective equipment storage container (portable kit containing items needed for personal protection such as gowns, gloves and hair nets) in the hallway outside of Resident 4's room. Observation at that same time revealed that an Activity Aide (AA) 1 was in the room preparing to paint Resident 4's fingernails. The AA 1 was wearing a hair covering and no other protective equipment.
During an interview with the Director of Nursing at the time of the observation, she confirmed Resident 4 was on contact precautions for head lice. She also revealed that staff providing care, including nail painting, should wear the protective equipment.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
| ||Plan of Correction - To be completed: 10/24/2019|
F 880 Infection Prevention and Control
1. How the facility will correct the deficiency as it relates to the individual.
Activities Aide#1 was educated on infection control policy and procedures for transmission based precautions.
2. How facility will act to protect residents in similar situations?
Residents on contact precautions that are receiving one to one activities have the potential to be affected by this alleged deficient practice. These residents will have the appropriate PPE utilized by staff.
3. Measures the facility will take or systems it will alter to ensure that the problem does not recur.
Activities aides have been reeducated on infection control policy and procedures for providing activities to residents on transmission based precautions and ensuring appropriate PPE is utilized.
4. How the facility plans to monitor its performance to make sure that solutions are permanent; i.e., what quality assurance programs will be established?
Administrator or designee will conduct random observations of residents on contact precautions that are receiving one to one activities to ensure that the appropriate PPE is being utilized by staff. These audits will be completed weekly times four and monthly times two or until substantial compliance has been achieved. Results will be reported to the Quality Assurance Committee for further recommendations.