§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.
|
Observations:
Based on review of select facility policies and procedures, observation, clinical record review, and staff and resident interview, it was determined that the facility failed to ensure the implementation of isolation precautions for two of three residents reviewed for transmission based precautions (Residents 28 and 30); implement enhanced barrier precautions for two of three residents reviewed for enhanced barrier precautions (Residents 103 and 107); enforce restriction-to-work guidelines for one of two staff that tested positive for COVID-19 (Employee 5); implement measures to monitor and prevent the growth of opportunistic pathogens within the facility's water system; and ensure an environment free from the potential spread of infection on one of four resident hallways (Maple hall, Resident 29).
Findings include:
Review of the Centers for Medicare and Medicaid Services (CMS) memo entitled, "Enhanced Barrier Precautions in Nursing Homes," dated March 20, 2024, revealed that nursing care facilities are to use enhanced barrier precautions (EBP, gown and glove use) for residents with chronic wounds or indwelling medical devices (i.e., indwelling urinary catheters) during high-contact resident care activities regardless of their multidrug-resistant organism status. High-contact activity would include things like dressing, transferring, changing linens, providing hygiene, changing briefs, wound care, or device care.
Clinical record review for Resident 103 revealed weekly pressure injury evaluation documentation dated August 20, 2024, that indicated Resident 103 had a pressure ulcer on his right heel.
Observation of Resident 103's room on August 21, 2024, at 9:22 AM revealed an EBP sign before entering his room and a yellow PPE (personal protective equipment, gowns, and gloves) divider on his door. Interview with Employee 13 (nurse aide) on the date and time of the observation indicated that the EBP in place for Resident 103 were necessary because he had a leg wound.
Clinical record review for Resident 103 revealed a new physician's order dated August 21, 2024, for staff to implement EBP related to a pressure ulcer of his right heel.
Observation of Resident 103's wound treatment on August 22, 2024, at 9:27 AM revealed Employee 2 (licensed practical nurse) and Employee 4 (registered nurse assessment coordinator) performed hand hygiene and donned gloves to begin the treatment. Neither Employee 2 nor Employee 4 donned an isolation gown. Employees 2 and 4 completed all the steps of removing Resident 103's soiled dressings, wound cleansing, and new dressing application without wearing an isolation gown.
Interview with Resident 107 on August 21, 2024, at 10:13 AM revealed that he had open wounds to his right lower extremity, and staff complete daily wound treatments. Resident 107 stated that staff wear gloves; however, staff do not don a gown when performing his wound care. Observation of Resident 107's room on the date and time of the observation revealed no evidence of the implementation of enhanced barrier precautions.
Observation of Resident 107's wound treatments on August 22, 2024, at 9:41 AM revealed Employee 2 and Employee 4 donned gloves to begin Resident 107's wound care. Neither employee donned an isolation gown. Employees 2 and 4 performed the steps of removing Resident 107's soiled dressings, cleansing the wounds, and applying new dressings on August 22, 2024, from 9:41 AM through 10:16 AM, without donning an isolation gown.
Interview with Employees 2 and 4 on August 22, 2024, at 10:16 AM confirmed that both Resident 103 and Resident 107 required EBP during their wound care; however, they did not gown for either resident to perform the wound care.
The CDC (Centers for Disease Control) Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007) revealed that contact (gown and glove use for all care) and standard (glove use only for care likely to contact bodily fluids) isolation precautions are required for multidrug-resistant organisms (MDROs, infections with bacteria that are resistant to multiple commonly used antibiotics; e.g., MRSA (Methicillin-resistant staphylococcus aureus), VRE (Vancomycin-resistant enterococcus), and ESBLs (bacteria that produces extended-spectrum beta-lactamase that is resistant to commonly used antibiotics), during active infection or colonization (presence of bacteria in the absence of symptoms).
Observation of Resident 28's room on the Oak hallway on August 21, 2024, at 9:24 AM revealed a yellow PPE divider on the door with gowns and gloves, and a plastic bin in the hallway that contained an additional PPE supply. No visible sign indicated what precautions were necessary to enter Resident 28's room. No sign indicated that visitors should check with the nurse before entering Resident 28's room.
Interview with Employee 8 (licensed practical nurse) on August 21, 2024, at 9:26 AM revealed that Resident 28 was diagnosed with ESBL in her urine and contact precautions were necessary for care. Employee 8 confirmed that there was no signage to indicate what level of isolation precautions was necessary for Resident 28.
Observation of Resident 28's room doorway on August 21, 2024, at 9:31 AM (after the surveyor's questioning) revealed that the facility added a sign to indicate contact precautions were necessary.
Clinical record review for Resident 28 revealed a laboratory report dated September 18, 2023, for a urine sample collected September 13, 2023, that indicated a urinary tract infection with ESBL Klebsiella Pneumoniae (bacteria resistant to commonly used antibiotics). The report stipulated that, "This patient may require isolation." The laboratory report indicated that the bacteria in Resident 28's urine was resistant to cephalosporins (large group of antibiotics derived from a mold that kills bacteria).
Nursing documentation dated September 18, 2023, at 5:16 PM revealed that the physician ordered oral Cefdinir (cephalosporin antibiotic), 300 milligrams (mg), twice daily, to treat Resident 28's urinary infection. The documentation indicated that Resident 28's family did not want the use of intravenous antibiotics.
A physician's order active September 19, 2023, through October 19, 2023, instructed staff to implement contact transmission based precautions due to the ESBL in Resident 28's urine.
There were no laboratory reports in Resident 28's clinical record that indicated her urine no longer presented ESBL infection before the discontinuation of contact isolation precautions.
Urinalysis laboratory reports dated December 10, 2023, and December 13, 2023, indicated that the multiple organisms in the collected specimen suggested that the sample was likely contaminated; or the resident was likely considered colonized (infected without symptoms).
A physician's order dated March 22, 2024, instructed staff to implement EBP.
Interview with the Nursing Home Administrator, the Director of Nursing, and Employee 3 (registered nurse/infection control prevention coordinator) on August 22, 2024, at 1:30 PM confirmed that the facility had no policy or acceptable standard (e.g., CDC guideline) that warranted downgrading Resident 28's isolation precautions from contact to enhanced barrier precautions.
The facility policy entitled, "Clostridium Difficile" last reviewed without changes on January 20, 2021, revealed that Clostridium Difficile (C. Diff) is transmitted the fecal oral route. Steps toward prevention and early intervention, which include ongoing surveillance and increase awareness of symptoms and risk factors among staff, resident, and visitors. Residents with diarrhea associated with C. Diff are placed on contact precautions. Residents with diarrhea and suspected C. Diff are placed on contact precautions while awaiting laboratory results. Residents with C. Diff are placed in a private room (if available). If a private room is not available, residents will be cohorted with a dedicated commode for each resident.
Clinical record review for Resident 30 revealed the following physician orders:
16 French, 10 milliliter balloon Foley (urinary) catheter for a diagnosis of obstructive and reflux uropathy (blockage of the urinary system).
Enhanced barrier precautions.
Vancomycin 125 mg every 6 hours by mouth for Enterocolitis (bowel inflammation) due to Clostridium Difficile (C. Diff, bowel infection) from August 13, 2024, until August 20, 2024.
Review of Resident 30's laboratory results dated August 1, 2024, revealed that she was positive for C. Diff.
Observation on August 20, 2024, at 9:32 AM and 12:30 PM and August 21, 2024, at 9:14 AM of the hallway outside Resident 30's room revealed that there was enhanced barrier precaution signage to indicate the need to utilize PPE (personal protective equipment, to prevent infectious disease transmission). There was no signage that indicated the need for contact isolation outside Resident 30's room. There was another resident located in Resident 30's room, but there was no commode noted in Resident 30's room for their individual use.
This surveyor reviewed the above information during an interview on August 22, 2024, at 2:00 PM with the Nursing Home Administrator and the Director of Nursing.
The CDC, "Return to Work Criteria for HCP (health care personnel) with SARS-CoV-2 (COVID-19) Infection," stipulated that HCP who were asymptomatic throughout their infection and are not moderately to severely immunocompromised could return to work after the following criteria have been met:
At least seven days have passed since the date of their first positive viral test if a negative viral test is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day five through seven).
Review of Employee 5's (licensed practical nurse) personnel records revealed that she tested positive for COVID-19 on December 25, 2023. Review of Employee 5's work schedule revealed that she worked regular hours on December 25, 26, 28, 29, 30, and 31, 2023.
Interview with Employee 3 and the Director of Nursing on August 22, 2024, at 1:11 PM confirmed the payroll records for Employee 5 indicated that she worked regular hours immediately following her positive COVID-19 testing. The interview also confirmed that the facility could not provide evidence of contact tracing (investigation to determine what resident(s) or staff may have been in contact with Employee 5 while she was positive for COVID-19 infection) or COVID-19 testing completed on other staff or residents in response to Employee 5's positive result.
The CDC current "Water Management Program Toolkit, Practical Guide to Implementing Industry Standards," indicated that many buildings need a water management program to reduce the risk for Legionella (bacteria that can grow and spread in water systems and can cause a serious type of pneumonia (lung infection) known as Legionnaires' disease) growing and spreading within their water system and devices. Developing and maintaining a water management program is a multi-step process that requires continuous review. Steps to building an effective Legionella water management program include:
A description of the building's water system using flow diagrams and a written description to include details like connections to the municipal water supply, how water is distributed, and location of water heaters/boilers.
Identification of potentially hazardous conditions such as areas where water temperature could promote Legionella growth or where water flow might be low.
Control measures (such as heating, adding disinfectant, or cleaning) that include where and how to monitor them. Control limits are the maximum value, minimum value, or range of values that are acceptable for the control measure.
Determine what corrective actions or contingency responses to take when control measures are outside the control limits established.
The facility's, "Legionella Water Management Program," last reviewed without changes on January 17, 2024, revealed that the water management program was comprised of elements that included: specific measures used to control the introduction and/or spread of legionella (e.g., temperature, disinfectants); the control limits or parameters that are acceptable and that are monitored; a diagram of where control measures are applied; a system to monitor control limits and the effectiveness of control measures; a plan for when control limits are not met and/or control measures are not effective; and the documentation of the program.
Interview with Employee 6 (maintenance director) on August 22, 2024, at 1:30 PM indicated that he had no documentation that the facility specified any control limits (e.g., water temperatures or concentration of disinfectants), that staff tested the effectiveness of any measures, or that the facility had a planned response should the findings indicate an ineffective water management program.
The surveyor reviewed the concerns regarding the facility's water management program during an interview with the Nursing Home Administrator, the Director of Nursing, and Employee 3, on August 22, 2024, at 2:30 PM.
An observation and interview of Resident 29 on August 20, 2024, at 9:24 AM revealed the resident lying in bed. An empty bed pan was observed directly on the floor, not covered, under the resident's bed. Resident 29 stated the bed pan was there "exactly how she liked it." Resident 29 stated she is independent in taking herself to the bathroom with her walker, but at night she wants the bed pan there for emergencies. If she needs to use it, she reaches under the bed to get it, places it back on the floor, and then in the morning takes it into her bathroom to empty and clean it, stating she does not want to disturb anyone.
Resident 29's care plan revealed an intervention for the use of diuretics noted that the resident may void in a basin, kept at bedside during the night per her preference, which was added on August 12, 2024, to the plan of care.
Concerns of contamination with the bed pan being stored directly on the floor and proper cleaning of the used bed pan was reviewed with the Nursing Home Administrator and Director of Nursing on August 21, 2024, at 2:00 PM.
Nursing documentation dated August 21, 2024, at 6:31 PM noted Resident 29 did not want to stray away from the routine of using the bed pan during the night and sliding it under her bed and the resident was educated on the potential infection control risk of storing the bed pan directly on the floor. It was noted the resident was given disposable pads to place the bed pan on top of and wrap over the top of the pan to limit contamination.
A follow up observation of Resident 29 on August 22, 2024, at 12:22 PM revealed the resident was lying in bed. A disposable pad was observed folded in half on the floor in front of the resident's air conditioning unit. Resident 29's walker was parked on top of half the pad, with half sticking out in front of the walker toward the resident's bed. An empty bed pan was observed directly on the floor under the resident's bed. Upon interview, Resident 29 stated she did not know what the pad was for that was under her walker. When asked where she was keeping her bed pan, Resident 29 stated, "Is it under the bed, Is it clean? I think I cleaned it." When Resident 29 was questioned if she was to put the bed pan on the pad, she the stated, "I don't know, is that what I am supposed to do with it?"
There was no evidence staff was checking on the storage of Resident 29's bed pan, or assuring the bed pan was cleaned properly to prevent the potential for contamination/infection.
The above findings regarding Resident 29 were reviewed with the Nursing Home Administrator and Director of Nursing on August 22, 2024, at 1:45 PM.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(3)(e)(1)(2.1) Management
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
| | Plan of Correction - To be completed: 09/27/2024
Employees 2 and 4 were educated regarding PPE usage for residents on Enhanced Barrier Precautions.
Resident 28 received appropriate signage regarding Contact Precautions during survey.
Resident 30's signage was corrected to indicate Contact Precautions during survey.
The Facility is unable to correct the issue with Employee 5 working when testing positive for COVID.
The Facility's Water Management Plan will be revised to indicate monitoring by the Maintenance Director.
Resident 29 now has a bedside commode.
Current residents on any type of precautions will be reviewed for accuracy of the type of precautions being followed, correct room signage, and proper PPE being used.
Facility staff will be re-educated on Infection Control protocols.
Random audits of infection control practices and protocols will be conducted by the Infection Preventionist/Designee for compliance with proper protocols weekly x 4 weeks, then monthly x 2 months. Results of the audits will be reviewed at QAPI.
|
|
