|§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 review of select facility policies, observation, and staff interview, it was determined that the facility failed to provide an environment free from the potential spread of infection regarding resident bedpans and basins for one of one resident reviewed (Resident 20).
Review of the facility policy entitled "Cleaning of Bedpans, Commodes, and Urinals," last reviewed without changes on December 3, 2019, revealed that personal care items must be kept separate from bedpans and urinals.
Observation of Resident 20's room on the following dates and times revealed that her bedpan and basin were sitting on top of one another either under the sink or under the shower bench in the resident's shower. Neither the bedpan nor the basin were bagged or covered to prevent the potential for infection and/or cross-contamination.
January 21, 2020, at 9:35 AM and 12:52 PM
January 22, 2020, at 9:23 AM and 12:15 PM
January 23, 2020, at 9:38 AM
Observation and concurrent interview on January 23, 2020, at 10:00 AM with the Director of Nursing confirmed and acknowledged the above findings.
28 Pa. Code 211.10(d) Resident care policies
Previously cited 1/25/19
28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 1/25/19
28 Pa. Code 211.12(d)(3) Nursing services
| ||Plan of Correction - To be completed: 03/24/2020|
1. On 01/23/2020 the bed pan and basin were removed from resident 20's bathroom and discarded.
2. A walk thru has been done to identify other rooms with bedpans and personal items stored together. No other rooms have been identified.
3. Licensed Staff, Certified Nursing Assistants and Housekeeping staff will be educated on Policy 1.11 Cleaning of Bedpans, Commodes, and Urinals; including the need to keep personal care items separate from bedpans and urinals.
4. The Director of Nursing or designee will walk thru rooms weekly for four weeks, biweekly for four weeks, and then monthly to identify rooms with bedpans and personal items stored together. Results of walk thrus will be presented at community QAPI meetings. Processes will be revised as indicated by findings of walkthrus.