§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 review of facility documentation it was determined that the facility did not ensure an effective infection prevention program was maintained related to hand hygiene observed for one of six residents observed. (Resident R6)
Findings Include:
Review of the facility policy titled, Handwashing/Hand Hygiene dated July 2023, reads, "Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections."
1.All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.
2.All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.
3.Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies.
4.Triclosan-containing soaps will not be used.
5.Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations:
a.When hands are visibly soiled; and
b.After contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and C. difficile.
6.Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations:
a.Before and after coming on duty;
b.Before and after direct contact with residents;
c.Before preparing or handling medications;
d.Before performing any non-surgical invasive procedures;
e.Before and after handling an invasive device (e.g., urinary catheters, IV access sites);
f.Before donning sterile gloves;
g.Before handling clean or soiled dressings, gauze pads, etc.;
h.Before moving from a contaminated body site to a clean body site during resident care;
i.After contact with a resident's intact skin;
j.After contact with blood or bodily fluids;
k.After handling used dressings, contaminated equipment, etc.;
l.After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident;
m.After removing gloves;
n.Before and after entering isolation precaution settings;
o.Before and after eating or handling food;
p.Before and after assisting a resident with meals; and
q.After personal use of the toilet or conducting your personal hygiene.
7.Hand hygiene is the final step after removing and disposing of personal protective equipment.
Observation of the second-floor unit on February 9, 2024 at 10:36 a.m. revealed a licensed nurse completing medication administration. Medication administration was observed for Resident R6. Licensed nurse, Employee E4, was observed during medication pass. When Licensed nurse, Employee E4. found out they were going to be observed they went to the nurse's station to obtain disinfecting wipes. Licensed Nurse, Employee E4, came back to the nursing cart and placed the disinfecting wipes container on the top of their cart. Licensed nurse Employee E4 sanitized their hands and put on new gloves. Licensed Nurse, Employee E4, then after noticing there was not much space on the top of the nursing cart, went to place the disinfecting wipes in the bottom drawer of the nursing cart, and they would not fit. Licensed Nurse, Employee E4 took them out of the drawer and the disinfecting wipe container fell on the floor. Licensed Nurse, Employee with gloves still on, picked up the disinfecting wipes container and placed them on the top of the nurse's station. Licensed Nurse, Employee E4 then started to pour medications while placing medication cards on the nurse's station. Licensed Nurse, Employee E4 did not disinfect the top of the nursing cart, remove their existing gloves, sanitizie their hands, and put on new gloves after picking up the disifecting wipes off the floor and placing them on the top of their nursing cart.
Observation of the first-floor unit on February 9, 2024 at 11:17 a.m. revealed Nurse Aid Employee E7 came out of a resident room with gloves on and a urine sample cup in their hand. Nurse Aid Employee E7 walked over to the nurse's station and placed a urine cup on the nurses station top counter for a moment while still in their hand. While doing this, Nurse Aid Employee E7, asked where they should put the sample, and Licensed Nurse, Employee E8 stated they would get a bag out of the closet. While Licensed Nurse, Employee E8 retrieved the bag from the closet, Nurse Aid Employee E7 placed the urine cup on the top counter of the nurse's station for a moment again and then picked it up and leaned on the nurse's station with both arms. After this, the Nurse Aid Employee E7 touched the side of their face with the back of their hand. Licensed Nurse, Employee E8 obtained a specimen bag from the closet and Nurse Aide Employee E7 then placed the urine sample cup into a specimen bag and it was given to licensed nurse Employee E8. Nurse Aide Employee E7 then threw their gloves in the trash on the medication cart, opened the door with the door handle to Tyler's place lounge, and went into Tyler's place lounge. Nurse Aide Employee E7 did not perform hand hygiene after taking off their gloves.
28 Pa. Code 211.12 (d) Nursing Services
| | Plan of Correction - To be completed: 03/12/2024
1. Resident #6 was assessed by a Licensed Nurse and there was no unfavorable outcome related to the facility's alleged deficient practice.
Employees #4 and #7 were educated regarding appropriate infection control practices and maintaining hand hygiene.
2. An audit of current staff will be conducted to ensure that hygiene competencies are current.
3. Education will be provided by DON/Designee to current staff regarding the components of this regulation with an emphasis on maintaining appropriate infection control practices and hand hygiene while providing care.
4. Random visual audits will be conducted by the DON/Designee of medication passes and resident care to ensure that appropriate hand hygiene is maintained. Audits to be conducted 2x a week for 4 weeks, then weekly x4 weeks, then monthly x2 months.
The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services / designee.
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