§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 observation, clinical record review, and review of facility documentation, it was determined that the facility failed to maintain proper infection control measures for COVID-19 (a highly contagious respiratory disease caused by the SARS-CoV-2 virus) in one of two nursing units (second floor).
Findings include:
A review of the facility documentation dated December 28, 2023, revealed 8 residents were residing in the designated COVID-19 rooms on the second floor.
Interview with the Nursing Home Administrator and Director of Nursing on December 27, 2023, at 9:30 a.m. revealed that the facility was having a COVID outbreak, 8 residents are located on the second floor. The required Protective Personal Equipment (PPE) for the COVID rooms as required by facilities policy " Transmission-Based Isolation Precautions that PPE to be donned upon entrance to the resident room includes goggle or face shield, facemask N95, disposable gowns, and gloves. PPE will be doffed prior to exit of the room and discarded in isolation bins placed inside of resident's doorway ". Every staff, and/or visitor going into COVID room must put on all PPE when going into the resident's room who are diagnosed with COVID.
Observation conducted on December 28, 2023, between 10:35 a.m. to 10:40 a.m. on the second floor, revealed Housekeepers, Employee E8 and E9 were going in and out of the COVID rooms without appropriate PPE such as mask N95, and face shield. Also, Employee E9 was observed exiting COVID room without appropriately doffing and putting dirty gown in a clean cart with other clean gowns. When Housekeepers, Employee E8 and E9 were interviewed, they both reported that they were train on PPE to be put on upon entrance and taken prior to exit COVID rooms.
On December 28, 2023, at 11:00 a.m. interview with Director of Nursing, Employee E3 and Assistant Director of Nursing, Employee E10, confirmed that all staff and visitor going into COVID rooms must put on all PPE when going into resident's room who are diagnosed with COVID and doffed when exiting by infection control policies and procedures.
28 Pa. Code 211.10(d) Resident care policies
28 Pa. Code 211.12(d)(1) Nursing services
28 PA. Code 211.12(d)(5) Nursing services
| | Plan of Correction - To be completed: 02/22/2024
Facility failed to maintain proper infection control measures for the covid-19 in one of two nursing units. Correction- Education session for proper PPE/donning and doffing with all housekeeping personnel on 12/28/23. Staff Education about infection prevention measures to be utilized during normal operating procedures and during outbreaks requiring specialized isolation measures completed and ongoing for all staff.
DON/designee will monitor PPE donning/doffing for completion and accuracy monthly for 3 months and if 100% compliance is achieved, will continue to monitor quarterly. Audit developed and DON/designee, in conjunction with NHA, will report monthly at QA/CQI meetings noting compliance, reeducation, and plans for ongoing improvement/compliance at quarterly QAPI.
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