§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.
|
Observations:
Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to 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 for one of 18 residents reviewed (Resident 48).
Findings include:
Review of facility policy, titled Enhanced Barrier Precautions, with a revision date of December 2024, and a last review date of January 15, 2026, revealed, in part, "1. Enhanced barrier precautions (EBPs) refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MOROs) during high contact resident care activities; 2. Enhanced barrier precautions apply when ...a resident has a wound or indwelling medical devices; 7. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). b. Personal protective equipment (PPE) is changed before caring for another resident. c. Face protection may be used if there is also a risk of splash or spray. 8. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. providing hygiene or grooming; d. changing briefs or assisting with toileting; e. transferring; f. providing bed mobility; g. changing linens; h. prolonged, high-contact with items in resident's room, with resident's equipment, or with resident's clothing or skin; i. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and j. wound care (any skin opening requiring a dressing)."
Review of Resident 48's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning) and unstageable pressure ulcer (an ulcer that has full thickness tissue loss in which the base of the wound is covered by slough [yellow, tan, gray green, or brown] and/or eschar [tan, brown, or black]) of the left heel.
Observations of Resident 48's room on June 1, 2026, at 2:02 PM, and June 2, 2026, at 9:20 AM and 1:33 PM, failed to reveal any signage that Enhanced Barrier Precautions were to be followed when caring for Resident 48.
During an observation of Resident 48's room door on June 3, 2026, at 11:13 AM, in preparation for observation of Resident 48's wound care with Employee 1 (Licensed Practical Nurse/ Wound Care Nurse), Employee 1 was observed to be marking Resident 48's name tag by her door with a blue highlighter.
During an immediate staff interview with Employee 1, he indicated that a resident on Enhanced Barrier Precautions has a blue name at their door. In addition, Employee 1 further confirmed that there should have been an Enhanced Barrier Precaution sign on Resident 48's door to alert staff of the appropriate infection control precautions to follow when providing care to Resident 48.
During a staff interview with the Nursing Home Administrator on June 3, 2026, at 1:26 PM, she confirmed that would have expected Enhanced Barrier Precautions to have been implemented properly for Resident 48.
28 Pa. Code 201.18(b)(1) Management.
28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.
| | Plan of Correction - To be completed: 07/01/2026
1. Resident 48 has had no negative outcome related to missing signage for EBP. Staff followed appropriate precautions during wound care with appropriate PPE during dressing changes. Signage was placed immediately during the survey.
2. Facility residents on EPB will be audited to ensure signage is current and placed in view on the resident's door.
3. Facility staff will be re-educated by Infection Preventionist/Designee on appropriate display of signage per facility policy for those requiring EBP.
4. Infection Preventionist/Designee will audit 10 residents on EBP weekly for 8 weeks to ensure EBP signage is in place on the door. The results of the audit will be reported monthly at the Facility Quality Assurance Performance Improvement meeting.
|
|
