§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 observations, staff interviews, and review of facility policy, it was determined that the facility failed to ensure COVID-19 infection control protocols were followed to help prevent the development and transmission of communicable diseases and infections on one of two floors (2nd Floor).
Findings include:`
The facility policy "COVID-19 Protocol," dated 7/1/20, revealed that residents must be masked if out of his or her room. Residents that are admitted from home and the hospital are under a 14-day COVID-19 prevention protocol.
During an interview on 7/16/20, 9:50 a.m. regarding the facility protocol and COVID-19 precautions, the Director of Nursing stated that activities and therapy should be done in the room; however, if they need to be done out of the room then the resident must be masked.
The clinical record for Resident R1 revealed an admission date of 7/8/20, for respite hospice stay, with diagnoses to include secondary malignant neoplasm (abnormal growth of cells) of the brain and bone, high blood pressure, anxiety, and dizziness.
The clinical record for Resident R2 revealed an admission date of 7/8/20, with diagnoses to include high blood pressure, depression, and Alzheimers (progressive disorder that causes brain cells to waste away and die).
Resident R1 and Resident R2 were cohorted in a room together on the 2nd floor.
During the facility tour on 7/16/20, at 10:17 a.m. Resident R1 was found seated in a wheelchair close to the nurse's station without a mask on. Resident R1 was on COVID-19 precautions starting on his/her admission date of 7/8/20 and through 7/22/20. During an interview with Nursing Assistant (NA) Employee E1 on 7/16/20, at 10:15 a.m. revealed that he/she didn't know that Resident R1 was still under COVID-19 precautions.
During an interview on 7/16/20, at 10:16 a.m. NA Employee E2 revealed that he/she was told during report that Resident R1 was under COVID-19 precautions but it wasn't anything to worry about.
During an interview on 7/16/20, at 10:17 a.m. Licensed Practical Nurse (LPN) Employee E3 indicated that Resident R1 should have a mask on when sitting out in the hall. LPN Employee E4 proceeded to place a mask on Resident R1 who did not voice any complaints or issues.
The facility failed to properly implement thorough infection control practices to help prevent transmission of communicable diseases for residents and staff by not properly educating all staff concerning COVID-19 precautions and ensuring all residents were wearing a mask as required.
28 Pa. Code 201.14 (d)(1)(5) Nursing services
Previously cited 7/25/19
| | Plan of Correction - To be completed: 08/27/2020
Facility immediately placed a mask on the Resident.
Employee 1, 2, 3, 4 were immediately re-educated on placing a facemask on Residents who are out in a common area while under Covid-19 precautions (surveillance).
A whole house Audit was performed to ensure no other resident was subjected to deficient practice. No further discrepancies noted.
Facility staff was educated by the Department of Health Regional Response Coalition Team on July 30, 2020. Education consisted of infection control practices that included: disinfecting during Covid-19, Contact, Standard, droplet and airborne precautions, hand hygiene, surgical mask/respirator use and the chain of infection. Additional staff re-education will also be provided by the Director of Nursing/designee to all Staff on Residents under COVID-19 precautions and mask wearing to prevent the spread of Covid-19. All new admissions or re-admissions who would be placed on the Covid-19 precautions (survellance) will also be educated on admission/readmission as to wearing of a mask so that the problem does not reoccur.
An audit will occur of all new Admissions/re-admissions placed on the Covid-19 precautions (surveillance) 5 times a week for 4 weeks weeks by the NHA/DON/ADON or designee to ensure protocol is being followed. Ad hoc education will immediately be provided to involved parties if a concern is found. Results of the audits will be reviewed and recorded in monthly QAPI meeting.
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