§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 a review of clinical records, PAHAN (Pennsylvania Health Alert Network) infection control guidance, select facility policies, and staff interview, it was determined that the facility failed to initiate necessary infection control precautions for cohorting a resident positive for COVID-19 to prevent the spread of the SARS-CoV-2 virus to uninfected resident. This failure placed the uninfected resident at risk to their health due to the likelihood of contracting the virus by continuing to reside in the same room as the infected resident and resulted in 1 resident out of three sampled being infected with COVID-19 (Resident 58) while residing with COVID positive roommate (Resident 20), and failed to maintain infection control practices related to reduce the potential for infections for one (Resident 8) out of four sampled residents with an indwelling urinary Foley catheter (flexible tube which is placed in the bladder to drain urine) and failed to ensure that infection control practices were implemented to reduce the potential spread of infection for one of two sampled residents with an infection (Resident 8).
Findings include:
According to information provided by the Pennsylvania Department of Health 2023-PAHAN-694 dated May 11, 2023, placement of residents with suspected or confirmed SARS-CoV-2 infection: ideally, residents should be placed in a single-person room. If limited single rooms are available, or if numerous residents are simultaneously identified to have known SARS-CoV-2 exposures or symptoms concerning for COVID-19, residents should remain in their current location. However, quarantined patients and those with suspected infection should NOT be cohorted with patients with confirmed SARS-CoV-2 infection unless they are confirmed to have SARS-CoV-2 infection through testing.
The facility has a licensed and certified bed capacity of 119 beds. At the time of September 23, 2023, the facility's census was 75 residents, and on September 24, 2023, the facility census was 74.
A review of Resident 20's clinical record revealed he was most recently admitted to the facility on June 8, 2023, with diagnoses to include atrial fibrillation (a irregular and often very rapid heart rhythm), diabetes, and chronic pulmonary embolism (a blood clot in the lungs).
A further review of a nurses note dated September 23, 2023, at 2:22 PM revealed a temperature of 101.5, pulse, 86, respirations 18, pulse ox 94% on room air. Tylenol given at 9:54 AM. Rechecked temperature 99.1, nasal congestion noted. Tested positive for COVID. Registered Nurse (RN), supervisors notified.
Review of resident 20's clinical record revealed on September 23, 2023, he resided in room East 105 bed 2. A review of Resident 58's clinical record revealed he was admitted to the facility on December 3, 2021, with diagnoses to include Alzheimer's Disease (the most common cause of Dementia, a gradual decline in memory, thinking, behavior and social skills, affecting a person's ability to function), Crohn's disease (swelling of the tissue in your digestive tract which can lead to abdominal pain, severe diarrhea, fatigue, weight loss and malnutrition), and chronic kidney disease.
A review of a nurses note dated September 20, 2023, at 4:17 AM revealed the resident was observed sleeping. Respirations easy and unlabored. Appears in no distress.
A review of a respiratory note dated September 23, 2023, at 1:26 PM revealed a COVID test, point of care (POC) result negative. MD made aware, no new orders received (N.N.O.R).
A further review of a nurses note dated September 24, 2023, at 1:41 PM revealed resident 58 had slight cough, temperature - 99.1, pulse -103, respirations -18, pulse ox -98% on room air (RA). No complaints of pain. Good appetite. Lungs clear to auscultation (LCA).
A continued review of a nurses note dated September 25, 2023, at 8:35 AM, stated the resident resting in bed with congested cough, lungs diminished, skin warm flushed. temperature 99.8, pulse ox 91% room air, pulse 98, Blood Pressure 140/88, respirations 18. COVID test, SARS CO-V2 with positive results. RN and Director of Nursing (DON) aware of same.
Review of resident 58's clinical record revealed on September 23, 2023, he resided in room East 105 bed 1. The facility failed to promptly isolate Resident 20, a resident with a symptomatic COVID-19 infection, to prevent potential transmission to Resident 58 according to current infection control guidance and facility policy.
Interview on January 31, 2024, at approximately 12:15 PM, with Employee 1, Registered Nurse (RN), the facility's Infection Preventionist (IP), confirmed that resident 20 had been symptomatic and tested positive for COVID 19, on September 23, 2023, and his roommate, resident 58 had tested negative for COVID 19, on September 23, 2023, and was without symptoms. Employee 1 further confirmed that both resident 20, and 58 had resided in room East 105, and that the facility did have rooms available to isolate residents that tested positive for COVID-19.
Interview with the Nursing Home Administrator on February 1, 2024, at approximately 9:45 AM, confirmed that the facility failed to implement infection control practices for cohorting and isolating COVID positive residents, to prevent the potential spread of COVID-19.
Review of facility policy titled "Isolation-Initiating Transmission-Based Precautions", reviewed by the facility on July 1, 2023, indicated that Transmission- Based Precautions (TBP) will be initiated when there is reason to believe that a resident has a communicable infectious disease. Transmission-Based Precautions may include Contact Precautions, Droplet Precautions, or Airborne Precautions. When TBP are implemented, the Infection Preventionist shall: A.Ensure that protective equipment (i.e., gloves, gowns, mask, etc.) is maintained near the resident's room so that everyone entering the room can access what they need; B.Post the appropriate notice on the room entrance door and on the front of the resident's chart so that all personnel will be aware of precautions, or be aware that they must first see a nurse to obtain additional information about the situation before entering the room; C.Ensure that an appropriate linen barrel/hamper and waste container, with appropriate liner, are placed in or near the resident's room; D.Place necessary equipment and supplies in the room that will be needed during the period of TBP; E.Be sure that an adequate supply of antiseptic soap and paper towels is maintained in the room during the isolation period; and F.Explain to the resident (or representative) the reason(s) for the precautions.
A review of clinical records revealed Resident 8 was admitted to the facility on December 28, 2023, with diagnoses to include sepsis (a condition in which the immune system has a dangerous reaction to an infection), urinary tract infection, and ESBL (Extended Spectrum Beta Lactamase, a bacteria resistant to most antibiotics) in the urine.
On December 28, 2023, the physician ordered that the resident be placed on contact precautions related to ESBL in the urine.
Observation on January 30, 2024, at 11:18 AM revealed that Resident 8's room, Room 307, did not have any posting on the entrance door to notify staff or visitors of any contact precautions, or instruct visitors to first see a nurse to obtain additional information about the situation before entering the room. There was no PPE (personal protective equipment) maintained near the resident's room so that everyone entering the room had access to what they needed. There was no appropriate linen barrel/hamper and waste container, with appropriate liner, placed in or near the resident's room.
Review of facility policy titled "Catheter Care, Urinary", last reviewed by the facility on July 1, 2023, indicated that the purpose is to prevent catheter-associated urinary tract infections. An aseptic technique and sterile equipment are used for catheter insertion, and the staff are to maintain a closed drainage system for indwelling catheter. Staff are to maintain a clean technique when handling or manipulating the catheter, and staff are to be sure the catheter tubing and drainage bag are kept off the floor.
Observation on January 30, 2024, at 11:18 AM revealed the Resident 8 was resting in bed. The urine collection bag from the resident's indwelling Foley catheter was laying on its side, directly on the floor.
Observation on January 31, 2024, at 9:25 AM revealed Resident 8 resting in bed. The urine collection bag was directly in contact with the floor.
Interview with Employee 1 (Infection Preventionist) on January 31, 2024, at 12:35 PM, confirmed that the facility failed to implement the facility's Infection Control Policies for Transmission-Based Precautions for Resident 8 by not posting signage on the entrance to her room, not ensuring that the appropriate PPE was readily available and not providing the appropriate linen/trash containers. Employee 1 also confirmed that the facility failed to maintain Resident 8's Foley catheter in a manner to prevent the potential for urinary tract infection and maintain infection control techniques for a resident with a Foley catheter.
28 Pa Code 211.10(a)(d) Resident care policies
28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.
| | Plan of Correction - To be completed: 03/13/2024
Unable to retroactively correct the deficiency for residents 58 and 20. Resident 8 urinary catheter bag was changed and removed from the floor and signage for transmission based precautions and PPE placed on door to residents room. Review of residents positive for COVD 19 will be reviewed to ensure single room placement is implemented. Residents medical records will be reviewed to ensure if transmission based precautions are needed and PPE and signage is on entrance to room as ordered. Will audit all residents with urinary catheter bags to ensure they are not touching the floor. Licensed staff re-educated on PA HAN 694, Policy for "Isolation-Initiating Transmission Based Precautions", and the policy for "Catheter Care, Urinary". New admissions and new infections will be reviewed at IDT meeting to determine need for isolation. DON/designee will audit residents positive for COVID 19 to ensure single patient room in is use. Will audit residents with urinary catheter bags to ensure they are not touching the floor and will audit 10% of residents with isolation needs to ensure signage and PPE is correctly placed on the entrance to the residents room weekly x4, then monthly x2. Results to QAPI for review and recommendations.
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