|§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 facility policy and clinical record review, observations and staff interviews, it was determined that the facility failed to use proper infection control technique which created the potential of cross-contamination during a dressing change for one of one resident reviewed (Resident R10).
Review of Resident R10's clinical record revealed that Resident R10 was admitted on 11/4/19 with diagnoses of major depressive disorder and pressure ulcer.
During an observation of a dressing change on 2/4/20 at 1:40 p.m., the following was observed:
Registered Nurse (RN) Employee E7 performed hand washing in Resident R10's bathroom sink. Licensed Practical Nurse (LPN) Employee E8 performed a two second hand wash. Gloves were applied at bedside. Resident R10 was uncovered, was turned toward LPN Employee E8, brief removed. RN Employee E7 placed used brief in biohazard bag, removed gloves, failed to use hand sanitizer and donned gloves. RN Employee E7 sanitized overbed table and created clean field, doffed gloves, failed to use hand sanitizer, donned gloves. RN Employee E7 removed old dressing, removed gloves, performed hand washing in sink. RN Employee E7 donned gloves at bedside, cleaned and swabbed wound, took skin prep from clean field, doffed gloves. RN Employee E7 donned gloves without hand sanitizer, packed wound, returned to clean field for scissors, back to wound, cut packing, picked up topical dressing and applied to wound, doffed gloves. RN Employee E7 then took sharpie from pocket and placed on clean field, cleansed sharpie with alcohol wipe, donned gloves, applied dressing on Resident R10's buttocks, doffed gloves. RN Employee E7 donned gloves without hand sanitizer, took brief from drawer and applied brief and rolled Resident R10 onto back. LPN Employee E8 removed gloves, turned off light, lowered bed, then pulled up Resident R10's pants, washed hands. RN Employee E7 donned gloves, cleaned up supplies, tied up biohazard bag, doffed gloves, hand sanitizer used, all other supplies gathered and placed in dressing change bag. RN Employee E7 took biohazard bag to bathroom, sat on floor while donning gloves from bathroom, took biohazard bag to biohazard room, opening two doors with gloved hands to dispose of bag, doffed gloves. RN Employee E7 washed hands in soiled utility room, returned to Resident R10's room to pick up supplies and tray, took to clean utility room, verbalized completion of dressing change. RN Employee E7 failed to sanitize over-bed table.
During an interview on 2/4/20 at 2:45 p.m., RN Employee E7 confirmed that proper infection control procedures were not maintained during the dressing change and created the potential for cross contamination.
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(e)(1) Management.
28 Pa. Code: 201.18(b)(1)Management.
28 Pa. Code: 201.20(c) Staff development.
28 Pa. Code: 211.10(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.
| ||Plan of Correction - To be completed: 04/06/2020|
1. Cited resident had no negative outcome.
2. Licensed Nurses will be educated on infection control procedures as it relates to wound dressing changes by center Director of Nursing or designee.
3. Each licensed nurse will be audited for proper infection control techniques during dressing changes.
4. Audits will be conducted by Director of Nursing or designee to ensure proper infection control procedures are utilized during dressing changes weekly x 4 weeks then monthly x 3 months.
5. Results of audits with recommendations for changes will be submitted to QAPI committee