§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.
§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 observations and resident and staff interview, it was determined the facility failed to ensure Enhanced Barrier Precautions (infection control prevention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) were in place for residents requiring enhanced barrier precautions for two of 19 residents (Residents 69 and 120).
Findings include:
Interview with Resident 69 on July 9, 2024, at 11:10 a.m. revealed the resident had a suprapubic catheter (tube that drains urine through the bladder via an incision in the abdomen).
Observation of Resident 120 on July 9, 2024, at 10:50 a.m. revealed the resident had a central line (catheter that goes into a vein that leads to the heart) and a left knee surgical wound.
Observations of Resident 69 and 120's rooms on all four days of the survey failed to reveal personal protective equipment located outside the rooms or signage indicating that the residents were on Enhanced Barrier Precautions.
Interview with the Director of Nursing on July 11, 2024, at 10:50 a.m. confirmed that Residents 69 and 120 were not on Enhanced Barrier Precautions.
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.5(f) Clinical records
28 Pa. Code 211.12(d)(1)(3)(5) Nursing service
| | Plan of Correction - To be completed: 07/12/2024
On July 11, 2024, the Director of Nursing (DON) posted Enhanced Barrier Precaution (EBP) signage and placed personal protective equipment (PPE) outside the rooms of Residents 69 and 120.
On the same day, the DON and the Infection Preventionist (IP) reviewed the facility's current residents to identify any potential additional instances of non-compliance with EBP. No additional instances were found.
On July 24, 2024, the IP provided education to the DON regarding Enhanced Barrier Precautions and the Simpson Policy titled "Enhanced Barrier Precautions – Skilled Nursing".
Starting on 7/29/2024, the DON or their designee will audit the current resident census three times a week for four weeks, then bi-weekly for another four weeks, and finally monthly for one month to ensure sustained compliance with EBP principles.
The results of these audits will be discussed during monthly Quality Improvement (QI) meetings. The QI Committee will decide if continued auditing is necessary based on achieving three consecutive months of compliance.
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