§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, resident clinical records, observations, and staff interviews, it was determined that the facility failed to use Personal Protective Equipment (PPE) appropriately, which created the potential for the cross-contamination and the spread of diseases and infections in two out of 18 droplet precautions (infection control measures designed to prevent the spread of infectious diseases that are transmitted through respiratory droplets) rooms. (Covid and Exposed Unit).
Findings include:
Review of facility policy "Isolation Procedure: Resident placement in Transmission-Based Precautions" dated 4/17/24, indicated transmission-based precautions (including droplet) will be implemented when indicated by suspicion or presence of infectious disease. Initiate precautions as indicated.
Review of facility policy "Personal Protective Equipment" dated 4/17/24, indicated personal protective equipment (PPE) is available at all times. PPE includes gowns, gloves, masks, eyewear.
Review of facility policy "Coronavirus (Covid-19) policy" dated 4/17/24, indicated facility leadership and clinical staff are implementing all reasonable measures to protect the health and safety of residents and staff during the current outbreak of coronavirus disease. Managing a confirmed or suspected Covid-19 individual: Staff entering or caring for the patient should follow recommendations for PPE.
During a tour of facilities covid and exposed to covid unit, that included rooms 227 through 236, on 1/30/25, at 10:45 a.m. revealed each room with droplet isolation signage by resident ' s door, and PPE available for usage.
During an observation on 1/30/25, at 10:55 a.m. Housekeeper Employee E2 was cleaning room and failed to wear appropriate droplet precaution PPE (gown, gloves, mask, eyewear).
During an observation on 1/30/25, at 11:00 a.m. Nurse Assistant (NA) Employee E3 was finishing providing care to a resident and failed to wear appropriate droplet precaution PPE.
During an interview on 1/30/25, at 11:07 a.m. NA Employee E3 stated that she should have had a gown, gloves, N-95 mask (respirator mask used for droplet isolation), and eyewear on when entering a room with droplet isolation signage hanging by the door.
During an interview on 1/30/25, at 11:10 a.m. Registered Nurse Employee E2 confirmed that staff should be wearing N-95 mask, gown, gloves, and face covering when entering droplet isolation rooms.
A review of resident ' s clinical record of residents residing in rooms 227 through 236 on 1/30/25, at 12:15 p.m. all had current physician orders for droplet isolation, testing of covid, and care plans where updated to reflect isolation needs.
During an interview on 1/30/25, at 1:15 p.m. Director of Nursing confirmed that the facility failed to use Personal Protective Equipment appropriately, which created the potential for the cross-contamination and the spread of diseases and infections in two out of 18 droplet precautions rooms. (Covid and Exposed Unit).
28 Pa. Code: 201.14(a) Responsibility of licensee.
| | Plan of Correction - To be completed: 02/14/2025
1. All residents in rooms 227-236 have been assessed by the DON to ensure that no harm has occurred by not wearing appropriate PPE in their rooms. No findings noted.
2. All Covid isolation rooms have been assessed to ensure that they have the appropriate signage outside of their rooms and orders.
3. IP or Designee will educate Employees on the appropriate PPE to wear in isolation rooms.
4. DON or designee will audit 5 covid isolation rooms for 4 weeks to ensure that staff are wearing appropriate PPE. All findings will be reported to QAPI.
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