§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 observations, review of facility policy, and staff interview, it was determined that the facility failed to prevent the potential for cross contamination (the spreading of germs/microorganisms from one surface to another) during wound care for one of five residents reviewed for wounds (Resident R16).
Findings include:
A facility policy entitled "Handwashing/Hand Hygiene" dated 9/14/23, indicated that staff are to perform hand hygiene after removing gloves.
A facility policy entitled "Dressing, Dry/Clean" dated 9/14/23, indicated that staff are to change gloves and/or perform hand hygiene after removing the soiled dressing, and after opening clean supplies.
Observation on 2/02/24, at 9:20 a.m. of wound care revealed Licensed Practical Nurse (LPN) Employee E6 removed the soiled wound dressing, changed his/her gloves, and failed to perform hand hygiene prior to donning (put on) clean gloves. LPN Employee E6 cleansed the wound, changed his/her gloves, and failed to perform hand hygiene prior to donning clean gloves.
During an interview at that time LPN Employee E6 confirmed that he/she should have performed hand hygiene after removing the gloves.
During an interview on 2/02/24, at 9:25 a.m. the Director of Nursing confirmed that staff are expected to perform hand hygiene after removing their gloves.
28 Pa. Code 211.10(c)(d) Resident care policies
28 Pa. Code 211.12(d)(1)(5) Nursing services
| | Plan of Correction - To be completed: 03/14/2024
For Employee E6 and all Licensed Nursing Staff education will be provided by the Assistant Director of Nursing no later than February 23, 2024 to ensure that proper hand hygiene is performed after removing gloves during dressing changes. There were no adverse effects due to the infection control issue. An audit of 10% of all dressing changes will be observed to include off shifts by the Assistant Director of Nursing or Designee 3 times a week for 2 weeks, 2 times a week for 2 weeks and weekly ongoing to ensure proper technique is maintained and will be monitored by the Director of Nursing.
The results of the audit will be reviewed by the monthly Quality Assurance meeting and recommendations will be instituted.
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