§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, observation and resident and staff interviews, it was determined the facility failed to consistently implement and maintain infection control practices to prevent the potential spread of infection for one resident requiring contact precautions out of 11 residents sampled (Resident 1).
Findings include:
Interview with the facility's Nursing Home Administrator (NHA) during entrance conference on February 22, 2024, at approximately 9:25 AM revealed that the facility currently had a resident with clostridium difficile [c-diff] (a bacterium infection that causes an infection of the colon), and indicated that strict infection control practice is to be maintained to prevent the spread of the infection.
A review of Resident 1's clinical record revealed admission to the facility on January 23, 2024, with diagnoses which have included malignant neoplasm of the prostate, chronic kidney disease, diabetes, COVID-19, bronchopneumonia, and C-diff.
A review of an admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated January 28, 2024, indicated that the resident was cognitively intact with a BIMS (brief interview to assess cognitive status) score of 15 (13 - 15 represents cognitively intact).
Resident 1's care plan, revised on February 12, 2024, indicated the resident has infection, Bronchopneumonia, and C - Diff with a goal that the infection will resolve without complications by target date April 29, 2024. Planned interventions, initiated February 7, 2024, were to provide medications, treatments, and labs as ordered, monitor, observe, document complications, adverse side effects related to medication use, and review with MD for recommendations, vital signs as ordered, and precautions per protocol to prevent infection.
A review of a microbiology report (lab result) dated February 10, 2024, indicated that the resident's stool sample was positive for C-diff. Nursing noted on February 11, 2024, at 1:19 AM, that new orders were noted for contact precautions, and Vancomycin (antibiotic).
Observation on February 22, 2024, at approximately 11:20 AM, a metal apron on the wall outside the resident's room, 101, with personal protective equipment (PPE) supplies and signage on the resident's door, regarding contact precautions required for C-diff. An observation inside the resident's room a plastic gray bin just inside the room on the right side with a sign above stating "please do not overfill bins", used for disposal of the PPE, and the lid to this bin was wide open when observed and soiled PPE inside. A wheeled metal bin used for the resident's laundry was also observed inside the room, on the right side approximately 6 - 8 feet away from the plastic bin.
Observation on February 22, 2024, at approximately 12:40 PM, revealed that Resident 1 was lying in bed with his bedside table positioned over the bed with his meal tray on top. The lid to the gray plastic bin of soiled PPE was again observed to be open exposing used PPE. The lid to the metal laundry bin was closed, but a hospital gown was hanging out of the closed bin, and a plastic insulated meal plate lid had been placed on top of the metal laundry bin.
Interview with the NHA, on February 22, 2024, at approximately 2:10 PM, confirmed that the facility failed to consistently implement and maintain infection control practices to prevent the potential spread of infection.
28 Pa. Code 211.10 (a)(d) Resident care policies
28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services
| | Plan of Correction - To be completed: 03/14/2024
Resident 1s room was reviewed trash and linens immediately emptied, lids placed correctly. No other residents currently on isolation. The DON or designee will educate all staff on infection/isolation guidelines to include the handling of soiled linens and ensuring all PPE is disposed of properly with trash not overflowing. The DON or designee will complete physical audits on isolation rooms to check for trash control and soiled linen storage 5x/week for 4 weeks and then 1x/week for 4 weeks then monthly until 100% compliance or three months. Adverse trends will be reported in QAPI.
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