§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 §483.71 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 review of facility policy, observations, and staff interviews it was determined that the facility failed to implement enhanced barrier precautions for four of seventeen residents reviewed (Resident R36, R50, R24, R48).
Findings Include:
Review of facility policy "Enhanced Barrier Precautions - Skilled Nursing" reviewed July 2, 2024, revealed the facility will utilize enhanced barrier precautions to prevent the spread of multidrug resistant organisms (MDRO). Enhanced barrier precautions (EBP) expand the use of personal protective equipment (PPE) beyond situations in which exposure to blood and bodily fluids is anticipated. Enhanced barrier precautions include the use of a gown and gloves during high-contact resident care activities for residents with, but not limited to, wounds and/or indwelling medical devices regardless of infection status and MDRO colonization.
Further review of facility policy revealed gloves, and gown should be available immediately outside the resident room, a waste container should be near the exit of the resident room, and EBP signage should be posted for the resident room.
Review of Resident R36's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated April 1, 2025, revealed the resident had an indwelling catheter (also known as foley catheter - a flexible tube placed through the urethra into the bladder to help urinate and collect urine into a drainage bag).
Review of Resident R50's quarterly MDS dated February 26, 2025, revealed the resident had pressures ulcers (an open ulcer, the appearance of which will vary depending on the stage).
Review of facility wound report dated April 13, 2025, confirmed Resident R50 had an arterial ulcer (open wounds caused by poor blood flow) on the right heel, and a stage III pressure ulcer (characterized by full thickness skin loss and visible fat tissue) on the sacrum.
Review of Resident R36's and R50's clinical records, including physician orders and comprehensive care plans, revealed no documented evidence enhanced barrier precautions were implemented in the plan of care.
Observations on April 21, 2025, at 11:00 a.m. revealed no evidence that signage was placed on Resdient R36's and R50's door to indicate that the resident's required enhanced barrier precautions. Further observations revealed no gowns or a waste container were available immediatey outside/near the exit of Resdient R36's and R50's doors.
Interview and observation on April 21, 2025, at 11:02 a.m. with Resident R36 confirmed the resident still had a catheter. When questioned, Resident R36 denied that staff wear a gown when providing care.
Interview on April 21, 2025, at 11:07 a.m. with Licensed Nurse, Employee E3, revealed the employee was unaware of any residents on the ground floor nursing unit that were on enhanced barrier precautions.
Observations on April 21, 2025, at 11:24 a.m. revealed Nurse Aide, Employee E4, was in room 013 making Resident R50's bed. When questioned, Nurse Aide, Employee E4, was unaware that Resident R50 was on enhanced barrier precautions.
Review of Resident R24's quarterly MDS dated March 27, 2025, revealed the resident had an indwelling catheter.
Observation on April 21, 2025 at 10:45 a.m. revealed no signage on Resident R24's door to indicate that the resident required enhanced barrier precautions.
Interview on April 21, 2025, at 10:45 a.m. with Resident R24 confirmed the resident still had a catheter and Resident R24 and family member denied that staff wear a gown when providing care.
Review of Resident R48's quarterly MDS dated March 30, 2025, revealed the resident had an indwelling catheter.
Observation on April 21, 2025 at 10:55 a.m. revealed no signage on Resident R48's door to indicate that the resident required enhanced barrier precautions.
Interview on April 21, 2025, at 10:57 a.m. with Resident R48 confirmed the resident still had a catheter.
Further observations revealed no gowns were available immediately outside of Resident R24's and R48's doors.
Interview on April 21, 2025, at 11:10 a.m. with Unit Manager, Employee E5, confirmed no enhanced barrier precaution signage was posted on Resident R24's and Resident R48's doors and no gowns were immediately available outside Resident R24's and Resident R28's doors.
28 Pa. Code 211.10 (d) Resident care policies.
28 Pa. Code 211.12 (d)(5) Nursing services.
| | Plan of Correction - To be completed: 05/30/2025
1- Residents R36, R50, R24, R48 were all placed on Enhanced Barrier Precautions. This includes PPE immediately available outside of the resident's room and a waste container near the exit of the room with signage posted for each resident's room.
All residents will be screened during the admissions process for the need of Enhanced Barrier Precautions prior to admission to the facility. The Director of Nursing/Designee will review the new orders report to determine if Enhanced Barrier Precautions needs to be initiated and added to a resident's plan of care.
All licensed staff will be educated on the policy and procedures of Enhanced Barrier Precautions and the location of where PPE will be readily available on the nursing units.
The Director of Nursing/Designee will perform random weekly audits times 4 then monthly audits times 4 then quarterly audits times 4 to assure the facility has implemented Enhanced Barrier Precautions for the required residents. Audit results will be reported by the Director of Nursing/Designee through the Quality Assurance meeting and/ or the Facilities Governing Body meetings for compliance.
Date of Corrective action May 30,2025
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