§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 §483.71 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 observation, clinical record review, and resident and staff interview, it was determined that the facility failed to implement appropriate enhanced barrier transmission-based precautions for three of 24 residents reviewed (Residents 2, 67, and 106)
Findings include:
Review of the memo entitled "Enhanced Barrier Precautions (EBP, gown and glove use) in Nursing Homes to Prevent the Spread of Multi-drug Resistant Organisms (MDRO, bacteria that are resistant to some antibiotics)" released by the Center for Medicaid and Medicare Services (CMS) on March 20, 2024, with an implementation date of April 1, 2024, revealed that nursing care facilities are to use EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. High-contact activity would include things like dressing, transferring, changing linens, providing hygiene, changing briefs, wound care, or device care.
Review of the facility policy titled, "Enhanced Barrier Precautions," reviewed without changes on March 27, 2025, revealed that it is the policy of the facility that EBP, in addition to standard contact precautions (refer to the infection prevention practices that apply to all residents, regardless of suspected or confirmed diagnosis or presumed infection status), will be implemented during high-contact resident care activities when caring for residents that have an increased risk for acquiring MDROs such as a resident with chronic wounds requiring a dressing, indwelling medical devices, or residents with infection or colonization (when a germ or microbe is found on or in the body but does not cause symptoms or disease) with an MDRO.
Further review of the policy revealed that EBP refers to an infection control intervention designed to reduce transmission of MDROs that employs targeted gown and glove use during high contact resident care activities (dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, assisting with toileting, device care, wound care).
The policy noted that EBP will not only focus on residents with an infection or colonization with an MDRO, but it will also address residents at risk for developing or becoming colonized. EBP require gown and glove use for residents with a novel or targeted MDRO or any resident with a wound or indwelling medical device during specific high-contact care activities.
Clinical record review for Resident 106 revealed the resident has bilateral heel pressure ulcers. The resident has current orders for wound care and antibiotic treatment related to the pressure ulcers.
There was no evidence in the clinical record to indicate that Resident 106 was on any type of enhanced barrier precautions or any type of isolation for the wound.
Observation of Resident 106's room on April 3, 2025, at 1:10 PM revealed no evidence that the resident was on EBP (no sign indicating EBP precautions, no personal protective equipment (PPE) in the room or at the doorway to don (put on and use), or any sign placed that instructed to see the nurse prior to care
Observation of Resident 106's wound care on April 3, 2025, at 1:10 PM revealed Employee 4, licensed practical nurse, and Employee 5, registered nurse, entered the resident's room and performed wound care to the resident's bilateral heels, which included a dressing change. There was dark colored wound drainage noted on the bed sheet of the resident's bed under the resident's heels. The staff did not wear gowns during the high contact activity of wound care with noted drainage.
The above information for Resident 106 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on April 3, 2025, at 2:15 PM.
Clinical record review for Resident 2 revealed a urinalysis dated March 18, 2025, that indicated she had ESBL (extended-spectrum beta-lactamase an enzyme found in some strains of bacteria that can't be killed by many of the antibiotics doctors use to treat infections) in her urine. Resident 2 was then hospitalized from March 19 to 25, 2025. There was no evidence in her clinical record that EBP was initiated upon her return from the hospital.
Observation of Resident 2's room on April 1, 2025, at 1:30 PM revealed no evidence that EBP was initiated.
The above information for Resident 2 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on April 3, 2025, at 2:00 PM.
Clinical record review for Resident 67 revealed current physician orders for a Foley (urinary) catheter to straight drainage every shift for a diagnosis of bilateral obstructive uropathy (blockage of the urinary system).
Observation on April 1, 2025, at 10:41 AM and 12:48 PM, April 2, 2025, at 12:47 PM and 12:53 PM, and April 3, 2025, at 8:41 AM of the hallway outside Resident 67's room revealed that there was no enhanced barrier precaution signage to indicate the need to utilize PPE (personal protective equipment, to prevent infectious disease transmission) and /or the necessary PPE available outside Resident 67's room though they had an indwelling medical device (Foley urinary catheter).
The above information was reviewed during an interview on April 3, 2025, at 3:11 PM with the Nursing Home Administrator and the Director of Nursing.
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.10(d) Resident care policies
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
| | Plan of Correction - To be completed: 05/13/2025
Residents 2, 67 & 106 had enhanced barrier precautions put in place.
Adon/designee to complete a house audit of all residents to identify any others requiring enhanced barrier precautions.
Licensed nurses will receive education related to how/when to put residents on enhanced barrier precautions. ADON/ designee to complete audits weekly x1 week, then monthly x 2 months to ensure enhanced barrier precautions are in place.
Results of these audits will be reported to the QA steering committee monthly x3 months, at which time the committee will determine the need for future audits.
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