|§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 clinical record review, observation and staff interview, it was determined that the facility failed to maintain infection control practices to prevent the spread of infection for one of one (Resident 47) dressing changes observed.
Review of facility policy titled, "7.1 dressing changes", with an effective date of October 1, 2018 states, "Apply clean gloves and remove the soiled dressing. Place dressing and gloves in plastic disposal bag and seal. Wash hands. Apply clean gloves. Cleanse area per physician's orders."
Review of Resident 47's clinical record revealed diagnoses including Anxiety Disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and essential hypertension (high blood pressure without a known cause).
Review of Resident 47's current physician orders dated February 12, 2020 revealed an order for cleanse open area right outer ankle with NSS (normal saline solution, a mixture of sodium chloride in water).
Observation of Resident 47's dressing change on February 13, 2020 at 9:36 AM revealed RN (Registered Nurse) 1 remove the dressing from Resident 47's right outer ankle, RN 1 then placed the dressing into the garbage bag, RN 1 then cleansed the wound with NSS and gauze without first washing her hands and applying new gloves.
Interview with the Director of Nursing on February 13, 2020 at 11:45 AM revealed that he would have expected RN 1 to follow facility policy and wash her hands and change her gloves after she removed the dressing, before she cleansed the wound.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
28 Pa. Code 201.18(e)(1) Management.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
| ||Plan of Correction - To be completed: 04/06/2020|
The Director of Nursing observed the unstageable area to R 47's right outer ankle to ensure no infection was present on weekly wound rounds completed on 2/18/20. No signs of infection were identified.
The Director of Nursing completed wound rounds on all resident with wounds on 2/18/20 looking for any signs of infection. No signs of infection were identifed.
The Director of Nursing or designee educated RN 1 on the Dressing Change Policy to wash hands after she removed the dressing, before she cleansed the wound with NSS.
The Director of Nursing or designee will educate licensed staff on the Dressing Change, Handwashing and Infection Control Policy.
The Director of Nursing or designee will complete Dressing Change Competencies of licensed staff.
The Director of Nursing or designee will observe dressing changes 5 times a week times 2 weeks and 3 times a week for 2 weeks on varying shifts to ensure physician orders, Dressing Change policy and Infection Control hand hygiene is being followed.
Results of audit will be reviewed at the Quality Assurance Quality Improvement. The Quality Assurance Quality Improvement Committee will determine if further monitoring is needed.