|§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.
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.
Based on observation and staff interview, it was determined that the facility failed to maintain infection control practices for one of 19 sampled residents ( Resident 50).
During an observation on February 9, 2020, at approximately 11 AM, Resident 50 was observed in bed. The resident's urinary foley catheter bag and tubing were observed positioned directly on the floor.
An additional observation on February 9, 2020, at approximately 11:45 AM revealed Resident 50 was seated in a wheelchair in the dining room. Observation in the resident's room at 11:50 AM on February 9, 2020, that the resident's oxygen tubing including the nasal canula were observed directly on the floor and the oxygen concentrator was running. Continued observation revealed that staff placed the resident back to bed at approximately 2 PM on February 9, 2020. Employee 6, a nurse aide, was observed to pick the oxygen tubing and nasal canula off the floor and placed the nasal cannula into Resient 50's nose. The oxygen concentrator had not been turned off and was resumed delivering oxygen therapy to the resident.
During an interview February 11, 2020 at approximately 10 an, the Director of Nursing confirmed the above observed breaks in infection control practices.
483.80 (a)(2) Infection control
previously cited 3/15/19
28 Pa. Code 2311.12 (c)(d)(1)(3)(5) Nursing services
previously cited 3/15/19
| ||Plan of Correction - To be completed: 03/10/2020|
Resident 50 had no adverse reaction.
To identify other residents with the potential to be affected, the DON / designee completed an audit to ensure all residents with oxygen tubing and foley catheters are properly positioned. Negative findings will be corrected.
To prevent this from reoccurring, the DON / designee completed education with staff to ensure they understand the IC prevention and control policy.
To monitor and maintain ongoing compliance the DON / designee will complete audits 3X weekly X4 weeks, then monthly X 2 to ensure oxygen and foley catheters are properly positioned. The DON / designee will compete 4 staff interview weekly X 4 then monthly X 2 to ensure they understand infection control practices. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Date of compliance March 10, 2020