§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.
§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 policies, observation, and staff interview, it was determined that the facility failed to make certain that proper infection control practices were followed during dressing change which created the potential for cross contamination for one of one residents (Resident R9).
Findings include:
Review of the facility policy "Standard Precautions" dated 3/25/19, indicated that the facility will provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Practicing hand hygiene is a simple but effective way to prevent the spread of infections by breaking the chain of infection. Hand hygiene will be performed before and after direct contact with resident's intact skin, after contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or dressing change. After glove removal.
Review of the facility policy "PPE Gloves" dated 3/25/19, indicated that hand hygiene is to be performed before gloves are applied and after gloves are removed. The policy reviews the process of glove removal, then discard in proper container and perform hand hygiene.
During an observation of a dressing change on 11/13/19, at 11:25 a.m. the Unit Manager Registared Nurse (RN) Employee E1 and Wound Care RN Employee E2 prepared Resident R9 for a dressing change of the right inner ankle area. The following was observed:
Wound Care RN Employee E2 removed gloves, carried sanitizing wipe container into restroom, opened door to restroom failed to perform handwashing when gloves were removed. Wound Care RN Employee E2 with ungloved hands placed wipe container in the wound cart. Wound Care RN Employee E2 then applied gloves, removed a sanitizing wipe, cleaned scissors, removed gloves and then gathered supplies for the dressing change without performing handwashing when gloves were removed. Wound Care RN Employee E2 removed Resident R9's old dressing, failed to place clean field under Resident R9's wound to protect the bedding. When dressing change was complete Unit Manager RN Employee E1 removed gloves, removed trash bag from bedside, placed the soiled wound dressing trash in the trash in the resident restroom without performing handwashing when gloves were removed. Wound Care RN Employee E2 verbalized that the dressing change was complete but did not label and date the new dressing and failed to return to Resident R9's room to sanitize overbed table.
During an interview on 11/13/19, at 12:00 p.m. Unit Manager RN Employee E1 and Wound Care RN Employee E2 confirmed that proper infection control procedures were not maintained during the dressing change which created the potential for cross contamination.
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(b)(1)(e)(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: 12/03/2019
Verified with PA Department of Health, Pittsburgh field office surveyor that dressing change observed on Resident E9 was to the left inner knee. Resident E9 wound area assessed 11/19/19, had no negative effect related to alleged deficient infection control practice.
Residents in house, with wound dressings had been assessed for signs and symptoms of infection by 11/20/19 by wound care nurse
The Director of Nursing and or designee has completed education with employee 1 and employee 2 on 9/13/19. The Director of Nursing and or designee will in-service Licensed Nurses on proper infection control procedures during dressing changes with wound dressing change competency by 12/3/19 The Director or Nursing or designee will complete proper handwashing technique with return demonstration with all staff by 12/3/19.
The Director of Nursing/Designee will complete audits of proper infection control procedures during dressing changes and proper handwashing procedures when donning and doffing gloves during dressing changes 3nurses weekly X 4 weeks. The results of these audits will be reported to the Quality Assurance Committee who will evaluate the results and make recommendations as needed.
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