|§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 clinical record review, observation, and staff interview, it was determined that the facility failed to implement an infection control program to prevent the potential spread of infection on two of four nursing units (Marble and Maple; Residents 96, 33, and 28).
Observation on February 5, 2020, at 10:36 AM revealed Resident 96 had a sign on her door indicating to see the nurse before entering. Concurrent interview with Employee 1, licensed practical nurse, revealed Resident 96 was on contact precautions (additional infection control precautions needed for those who have certain types of infections to prevent the spread of infection) due to c-diff (clostridium difficile, a bacterial infection that causes a mild to life threatening form of diarrhea) and colitis (a serious inflammation of the colon). Employee 2, nurse aide, was in Resident 96's room making the bed. A gown and gloves that was used by Employee 2 was on the seat of a chair in the room and not in a plastic bag. Employee 1 indicated that the gown and gloves should not have been placed on the chair and that they should have been discarded properly. Employee 1 discarded the gown and gloves by applying gloves and placing the gown and gloves in a plastic bag, and then discarded them into the trash receptacle.
Interview with Employee 5, registered nurse, on February 6, 2020, at 10:00 AM revealed that Employee 2 was employed through an agency, and that she had training on infection control prevention.
Nursing documentation dated February 5, 2020, at 3:14 AM revealed that Resident 96 continues antibiotics for a c-diff infection.
The surveyor reviewed the above findings for Resident 96 during an interview with the Director of Nursing on February 6, 2020, at 11:00 AM.
Observation of Resident 33's room on February 3, 2020, at 9:30 AM revealed a sign on her door indicating that you were to see the nurse before entering. The surveyor asked Employee 4 (licensed practical nurse), who identified herself as the charge nurse, why the sign was posted. She responded that she did not know.
Clinical record review for Resident 33 revealed she is on contact precautions for Extended Spectrum Beta-Lactamases (ESBL, which causes a hard to treat urinary tract infection).
Observation of Employee 3, nurse aide, on February 3, 2020, at 9:42 AM revealed that she was handling soiled linen with ungloved hands. She placed the soiled linen on a resident's bed and then put the soiled linen in a bag.
Observation of Resident 28 on February 3, 2020, at 9:45 AM revealed a urinal full of urine hanging on the waste can. A soiled paper towel was stuck on the side of the urinal. On the other side was a large amount of what appeared to be thick blood tinged sputum. The urinal itself appeared dirty.
An interview with Resident 28 at the time of the observation revealed that staff usually wait until the urinal is full before they empty it. He also indicated that staff keep telling him that he needs a new urinal, but he never got one.
The surveyor reviewed the above findings for Residents 33 and 28 during an interview with the Nursing Home Administrator and the Director of Nursing on February 4, 2020, at 2:00 PM.
483.80(a)(1)(2)(4)(e)(f) Infection Prevention and Control
Previously cited 3/8/19
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
Previously cited 3/8/19
28 Pa. Code 201.18(b)(1) Management
| ||Plan of Correction - To be completed: 03/18/2020|
1. Infection Control procedures have been reviewed relative to resident 28, 33, 96 and Marble/Maple Hall.
2. Current Infection Control practices have been reviewed to maintain an infection prevention and control program to provide a safe and sanitary environment.
3. All appropriate Staff have been re-educated on Facility Infection Control practices.
4. DON/designee will audit Compliance amongst staff with all Infection Control Practices. Results of audits will be reported to QA Committee for review and recommendations.
5. Corrective Action Date: March 18, 2020.