|§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 observations, clinical record, and staff interview, it was determined that the facility failed to ensure implementation of infection control practices for one of four residents observed during medication administration (Resident 37) and one of four residents on isolation precautions (Resident 38).
Review of Resident 37's clinical record on December 10, 2019, at approximately 11:00 AM, revealed diagnoses including hypertension (elevated/high blood pressure) and cerebral vascular accident (CVA, sudden loss of blood flow to a part of the brain and/or bleeding within the brain which causes physical and psychological deficits and can lead to death; also referred to as a "stroke").
During medication observations on December 10, 2019, at approximately 10:10 AM, upon entering the room for medication administration, Resident 37 was in the bathroom. LPN 1 assisted Resident 37 with toileting via locating a brief and helping to transfer Resident 37 into a wheelchair. LPN 1 performed hand hygiene appropriately after Resident 37 was transferred to a wheel chair. LPN 1 proceeded to Resident 37's bed side table and placed a tissue on Resident 37's bedside table. LPN 1 then emptied a medicine cup, containing oral medications for Resident 37, into LPN 1's ungloved, left hand. LPN 1 then used her ungloved, right hand to pick up the medications, individually, and laid them out in a resident preferred order on the tissue. Resident 37 then took each pill orally.
During a staff interview on December 12, 2019, at approximately 12:45 PM, Director of Nursing revealed it was the facility's expectation that staff do not handle resident's medications with their ungloved hands.
Review of the current Infection Control policy stated that the purpose of the facility Infection Prevention and Control Program is to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections, and to improve antibiotic use. Further review of the policy states that transmission based precautions should be followed and hand hygiene procedures should be followed by staff involved in direct resident contact.
Review of the clinical record for Resident 38 revealed diagnoses that included hypertension (elevated blood pressure) and cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area).
On December 6, 2019, the physician ordered testing to rule out respiratory syncytial virus (RSV - a contagious virus infecting the respiratory tract). There was also a new order on December 6, 2019, for contact precautions while ruling out RSV.
Observation on December 8, 2019, at 11:00 AM revealed Nurse Aide (NA) 7 entered Resident 38's room. She exited the room with Resident 38's water pitcher and filled the pitcher with ice water. She then entered the room and delivered the water pitcher. No gloves were worn and no hand hygiene was performed.
During an interview with the Director of Nursing on December 10, 2019, at 2:35 PM, she stated that she would have expected NA 7 to perform hand hygiene.
On December 10, 2019, the facility provided education that NA 7 received about hand hygiene and cross contamination with contact precaution/isolation rooms.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
| ||Plan of Correction - To be completed: 01/14/2020|
1. Education provided to involved staff during survey
2. Audits of staff for hand hygiene with contact with residents on precautions to be completed by DON or designee for the first three days post admission for two months then reviewed by QAPI for ongoing need. Med pass audits for licensed staff assigned to Res 37 to be completed
3. Education to nursing staff on hand hygiene with precautions and education to licensed staff on use of gloves while handling medication completed
4. Random med pass audits of 3 licensed nurses weekly x 4 then monthly x 2, random hand hygiene audits of 5 nursing staff weekly x 4 then monthly x 2 by DON or designee
5. DOC 1/14/20