§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 facility policy, clinical record review, observation, and staff interviews, it was determined that the facility failed to follow enhanced barrier precautions during high contact activities and failed to follow hand hygiene procedures during a dressing change for one of two residents (Resident R6).
Findings include:
Review of the facility policy " Enhanced Barrier Precautions (EBP) Policy" last reviewed 3/3/25, indicated team members are required to use gown and gloves during high-contact resident care activities that might result in transfer of Multi Drug Resistant Organisms (MDROs) to staff hands and clothing. Examples of high contact resident care activities requiring a gown and gloves for EBP include transfers. EBP should be in place for the resident's entire stay in the community unless the wound closes.
Review of the facility policy "Handwashing/Hand hygiene" last reviewed 3/3/25, indicated the facility considers hand hygiene the primary means to prevent the spread of infections. For washing hands, vigorously lather hands with soap and water and rub them together, creating friction, for a minimum of 20 seconds (or longer) under a moderate stream of running water, at a comfortable temperature. Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry towel.
Review of the clinical record indicated Resident R6 was admitted to the facility on 4/16/25, with diagnoses of hypertension (high blood pressure), muscle wasting and atrophy, and Parkinson's Disease (a brain condition that causes problems with movement, mental health, sleep, pain and other health issues).
Review of Resident R6's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/3/26, revealed the diagnoses were current.
Review of Resident R6's physician order dated 2/13/26, indicated to cleanse the left heel wound with normal saline solution (wound cleanser), pat dry, apply veris dressing (an advanced wound care product that combines collagen and Manuka honey) to wound bed. Cover with abdomen and wrap and Kling every day.
Review of Resident R6's physician order dated 2/17/26, indicated to implement Enhanced Barrier Precautions.
During an observation on 2/18/26, at 7:40 a.m. the Director of Nursing (DON) and Registered Nurse (RN), Employee E1 failed to implement Enhanced Barrier Precautions to transfer Resident R6 from the wheelchair to recliner in his room.
During an observation of Resident R6's wound dressing change on 2/18/26, at 7:43 a.m. RN, Employee E1 failed to follow proper hand hygiene procedures for seven of seven opportunities. RN, Employee E1 failed to ensure handwashing was completed for a minimum of 20 seconds. RN, Employee E1 failed to turn off faucets with a clean, dry paper towel for two of seven occasions.
During an interview on 2/18/26, at 8:00 a.m. RN, Employee E1 and the DON confirmed the facility failed to follow enhanced barrier precautions during transfers and failed to follow hand hygiene procedures during a dressing change for one of two residents (Resident R6).
28 Pa. Code: 201.14 (a) Responsibility of licensee.
28 Pa. Code: 201.18 (b)(1)(e)(1) Management.
28 Pa. Code: 211.10 (d) Resident care policies.
28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services.
| | Plan of Correction - To be completed: 03/13/2026
Employee E1 and DON were re-educated on maintaining enhanced barrier precautions and handwashing by Infection Control Practitioner.
All nursing staff will be re-educated on enhanced barrier precautions and handwashing by Infection Control Practitioner/designee.
Director of Nursing/infection control practitioner/designee will observe handwashing and use of enhanced barrier precautions during resident care. 10 audits will be conducted per week x 4 weeks, then monthly or until substantial compliance is achieved.
Results of audit will be reported at Quarterly QA meeting.
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