|§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 observation and staff interview, it was determined that the facility failed to ensure soiled linens and trash were stored in a sanitary manner, for one of two units observed (300 unit).
Observation of the 300 unit on February 5, 2020, at approximately 11:20 a.m., revealed in room 317, and 314, the red containers identified for infection control containment of bedding and waste were overflowing.
Observation on February 5, 2020, at approximately 11:30 a.m., revealed in room 315, two red containers overflowing with bagged linens and trash.
Observation on February 5, 2020, of Resident R5 walking in hallway with catheter tubing dragging on the floor.
Observation on February 5, 2020, at approximately 12:08 p.m., revealed the Director of Nursing picked up a soiled gauze padding from hallway floor without infection control protection gloves.
Interview occurred on February 5, 2020, at approximately 3:00 p.m,. with Director of Nursing when the above observations were presented.
28 Pa Code 201.18(b)(1) Management
| ||Plan of Correction - To be completed: 03/16/2020|
Staff removed overflowing red containers in identified rooms 317, 314, and 315, disposed the contents according to infection prevention guidelines, and replaced all container liners. All residents could be at risk from this deficiency. Staff rounded on all rooms to inspect all trash and linen containers. Containers were emptied as needed and contents disposed according to infection prevention guidelines. Leadership Rounds have been initiated and include weekly review of these infection prevention practices. Data collected during these rounds will identify any ongoing education or performance gaps on infection prevention practices, and interventions will be implemented as needed. Catheter of resident R5 was re-secured to leg of resident, tubing redirected, and privacy bag applied. Hand hygiene education and safe disposal of debris on floor will be conducted. Infection prevention topics will be included in all monthly staff meetings and in annual education for all staff. Monitor infection prevention data collected in Leadership Rounds will be reported in QAPI meetings.