§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 §483.71 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 policy review, observation, and staff interview, it was determined that the facility failed to administer medications in a manner that prevents the spread of infections on one of two nursing units. (West Wing)
Findings include:
Review of the facility policy entitled, "Infection Control Plan: Standard Precautions," last reviewed January 31, 2025, revealed that gloves should be worn whenever exposure to the mucus membranes (soft tissue that lines the body's canals and organs, such as the eye) is planned or anticipated.
On May 20, 2025, at 9:11 a.m., Licensed Practical Nurse (LPN) 1 was observed administering medications to Resident 33. The nurse applied Ocusoft lid scrubs to the eyes of the resident with her ungloved hands.
In an interview on May 21, 2025, at 9:30 a.m., the Director of Nursing confirmed that the nurse should have been wearing gloves to administer medications around the eyes.
28 Pa. Code 211.10(d) Resident care policies.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
| | Plan of Correction - To be completed: 07/11/2025
Resident 33 did not have any adverse effects.
All licensed nursing staff will be educated on ophthalmic medication and treatment administration, including infection control considerations.
The DON or Designee will conduct medication administration audits of ophthalmic medications and treatments weekly for four weeks and then monthly for three months. All audits will be tracked quarterly through the Quality Assurance Performance Improvement Committee.
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