|§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 observations, review of facility policy, and staff interview, it was determined that the facility failed to properly follow hand hygiene procedures during the administration of medications to five of 16 residents (Residents R30, R36, R51, R54 and R63).
The facility policy "Handwashing/Hand Hygiene Policy," dated 6/2016, indicated that "Employees must perform appropriate ten (10) to fifteen (15) second handwashing using antimicrobial or non-antimicrobial soap and water and if hands are not visibly soiled, use of an alcohol-based hand rub containing 60-95% ethanol or isopropanol is acceptable for all the following situations: Before preparing or handling medications."
Observations on 1/27/20, during medication administration revealed the following:
At 3:37 p.m., Licensed Practical Nurse (LPN) Employee E1 administered two oral medications to Resident R54, and did not wash his/her hands and/or use alcohol-based hand rub before or after medication administration.
At 3:43 p.m., LPN Employee E1 administered one oral medication to Resident R30, and did not wash his/her hands and/or use alcohol-based hand rub before or after medication administration.
At 3:47 p.m., LPN Employee E1 administered one oral medications to Resident R63, and did not wash his/her hands and/or use alcohol-based hand rub before or after medication administration.
At 3:50 p.m., LPN Employee E1 administered two oral medications to Resident R36, and did not wash his/her hands and/or use alcohol-based hand rub before or after medication administration.
At 3:57 p.m., LPN Employee E1 administered two oral medications to Resident R51, and did not wash his/her hands and/or use alcohol-based hand rub before or after medication administration.
During an interview on 1/27/20, at 4:00 p.m. LPN Employee E1 confirmed that he/she did not follow proper hand hygiene procedures. During an interview on 1/30/20, at 1:19 p.m. the Director of Nursing confirmed that the facility policy is to provide proper hand hygiene before preparing or handling medications.
28 PA Code 211.12(d)(1)(5) Nursing services
Previously cited 12/11/19 and 2/07/19
| ||Plan of Correction - To be completed: 03/20/2020|
On 1/30/2020 the Medical Director was notified by the director of nursing that R30, R36, R51, R54 and R63 received medications from LPN that did not follow proper hand washing as per policy. Medical Director determined no negative outcome.
On 1/30/2020 the policy was reviewed by Director of Nursing and Quality assurance registered nurse and it was determined no changes needed at this time.On 1/30/2020 Nurse(LPN) E1 was given a copy of policy and reviewed with the director of nursing.
The registered nurse staff developer will review our hand washing policy and do an in service with all licensed nurses to assure proper hand washing between medication passes.
The facility will monitor for continued compliance of proper hand washing during medication passes through audits by the quality assurance registered nurse throughout all shifts.Quality assurance registered nurse and/or designee will do audits on med passes to monitor proper hand hygiene with med passes five times a week for four weeks, then weekly times 4 weeks, then monthly times 2 months. These audits will be reviewed with quality assurance process improvement committee monthly times two. The QAPI committee will determine the frequency of audits thereafter.
Corrective plan of action completion date: March 20, 2020