|§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 professional literature, review of facility policies and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to wearing the appropriate personal protective equipment for one of five nursing units reviewed (C-Wing nursing unit).
Review of the Pennsylvania Department of Health's 2021-PAHAN-599 "Update: Response to an Outbreak and Residents with Exposure to COVID-19 for Long-term Care Facilities" dated September 24, 2021, revealed that upon identification of one or more cases of COVID-19, the facility should carefully consider options to conduct an outbreak response, including: use of contact tracing, use of a unit-based approach or use of a facility-wide approach to identify exposed residents and staff. Continued review revealed that to implement Zone-based guidance in the facility, refer to PAHAN-570.
Review of the Pennsylvania Department of Health's 2021-PAHAN-570 "Update: Response to an Outbreak and Residents with Exposure to COVID-19 for Long-term Care Facilities" dated May 10, 2021, revealed that residents pending test results but are within 14 days of known or possible exposure to COVID-19 are cohorted in a Yellow Zone (Quarantine). Continued review revealed that full PPE (personal protective equipment) must be used to care for residents in quarantine zones.
Review of facility policy, "PPE Usage in Yellow Zone" undated, revealed that "Yellow Zone = COVID-19 Exposed; Precaution: Contact and Droplet." Continued review revealed, "Required PPE Usage At ALL times: N95 Respirator, Goggles/Face Shield." Further review revealed, "Required PPE Usage During ALL patient care: N95 Respirator, Goggles/Face Shield, Gloves, Gown."
Review of facility documentation, dated November 6, 2021, revealed that the facility received test results from their laboratory provider for COVID-19 testing on November 6, 2021, at 9:21 a.m. which indicated that a staff member tested positive for the COVID-19 virus. The Nursing Home Administrator (NHA) informed the Director of Nursing (DON) and the Infection Preventionist on November 6, 2021, at 7:16 p.m. of the positive test result.
Interview on November 7, 2021, at 9:30 a.m. Employee E18, Nursing Supervisor, revealed that the C-Wing nursing unit was a Yellow Zone and the entire unit was in quarantine related to a staff member who recently tested positive for COVID-19.
Observations during initial tour of the C-Wing nursing unit on November 7, 2021, between 9:34 a.m. through 10:56 a.m. revealed the following:
A sign was posted on the main door entering the unit which indicated, "Yellow Zone."
Observation on November 7, 2021, at 9:35 a.m. Employee E11, licensed nurse, was observed going in and out of resident rooms administering medications. Employee E11 wore a surgical mask and did not have on an N95 mask, goggles/face shield or gown while providing resident care. Interview at the time of the observation, Employee E11 stated that the unit went "Yellow" yesterday, that no isolation gowns were available on the unit and that she was "waiting for the supervisor to bring some eye shields."
Employee E13, licensed nurse, was also observed going in and out of resident rooms administering medications. Employee E13 wore only a surgical mask, she did not have on an N95 mask, goggles/face shield or gown while providing resident care.
Interview on November 7, 2021, at 10:15 a.m. Employee E16, nurse aide, confirmed that the C-Wing nursing unit was a Yellow Zone Quarantine unit. Continued interview revealed that the employee was only wearing a surgical mask because other PPE (N95 masks, face shields, gowns) were not available on the unit.
Observation on November 7, 2021, at 10:30 a.m. revealed Employee E17, nurse aide, provide a.m. care to Resident R179 in his room. Employee E17 wore a surgical mask, face shield and gloves while providing care. Interview at the time of the observation, Employee E17 revealed that N95 masks and isolation gowns were not available on the unit and that staff were waiting for PPE to be brought to the unit.
Observation on November 7, 2021, at 11:56 a.m. revealed that carts with PPE, including isolation gowns, gloves, face shields and N95 masks were set up on the unit.
Continued observation on November 7, 2021, at 12:29 p.m. revealed Employee E13 entered resident room 317-A and obtained a fingerstick blood sugar reading. Employee E13 wore a surgical mask and gloves while providing care, and did not have on an N95, face shield or gown.
Observation of the luncheon meal on the C-Wing Unit on November 7, 2021, at 1:01 p.m. revealed Employees E13, E17, E14 and E12, unit manager, distributing trays to residents in their rooms as well as in the dining room. Employees E13 and E14 wore only N95 masks, Employees E17 and E12 wore N95 masks and face shields. None of the employees wore gowns or gloves while distributing and setting up the meal trays.
Continued observation on the C-Wing nursing unit on November 8, 2021, at 9:52 a.m. revealed licensed nurses, Employees E19 and E11, going in and out of resident rooms administering medications. Employees E19 and E11 wore N95 masks and face shields, however, neither employee wore a gown while providing resident care.
Interview of November 8, 2021, at 11:40 a.m., with Infection Preventionist, Employee E20, revealed that the C-Wing nursing unit was converted to a Yellow Zone Quarantine unit after an unvaccinated staff member who worked on that unit tested positive for COVID-19. Employee E20 confirmed that she became aware of the positive test result on November 6, 2021, and that the nursing supervisor on duty was informed and instructed to convert the unit to a Yellow Zone. Employee E20 was unable to explain why PPE was not promptly put on the unit on November 6, 2021. Employee E20 stated that when working in Yellow Zones, staff are required to wear full PPE, including N95 masks, eye protection, isolation gowns and gloves for all resident care activities which include medication pass, personal care and meal tray distribution.
Interview on November 9, 2021, at 9:15 a.m. the NHA stated that the facility chose to implement zone based guidance and quarantine the entire C-Wing unit after exposure to the staff member who tested positive for COVID-19 who had worked on that unit, because that worker had contact with many residents and because the residents on that unit are very mobile and difficult to contain to their rooms.
28 Pa Code 201.14(a) Responsibility of licensee
28 Pa Code 211.12(d)(1) Nursing services
| ||Plan of Correction - To be completed: 12/24/2021|
This Provider submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.
1. A Yellow Zone was immediately established on C wing. Employee E11, E12, E13, E14, E16, E17, and E19 were immediately educated on the importance of wearing appropriate PPE in the Yellow Zone. PPE items was made available to the unit and extras remain in central supplies.
2.All residents on C-Wing were swabbed for Covid-19, Zone base guidance and quarantine was immediately initiated for the entire C-wing due to an employee testing covid-19 positive whom have worked on the unit.
3.Infection preventionist/Designee will re-educate staff regarding "Covid-19 Response to Outbreak and residents with Exposure to Covid-19."
4.Infection control rounds on yellow zones will be conducted daily throughout an outbreak/exposure by the Infection preventionist/designee to assure that proper PPE is being utilized, hand hygiene is being perform in between contacts, with meals and care and supplies are available. Finding will be reviewed and discussed at the monthly QAPI meeting to determine further action is needed.