§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.
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Observations:
Based on observation, review of facility policy and procedure and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to appropriate cleaning techniques for medical equipment, on four of the seven Medication Administration Reviews (Residents R20, R176, R195, R227), and the Enhanced Barrier Precautions for four of seven residents treatments reviewed (R97, R168, R176, R195).
Findings include:
Review of facility policy titled "Infection Prevention and Control Program" revised June 2022, revealed the facility has an infection prevention and control program which monitors development and transmission of communicable disease and infections to promote safe sanitary and comfortable environment for residents' staff and visitors. Policies of this program include standard of transmission-based precautions and how and when isolation should be used for a resident including type and duration of isolation hand hygiene procedures.
Review of facility policy and procedure titled "Guidelines for Isolation Precaution" revised March of 2023 revealed the policy is to reduce the risk of the transmission of infectious agents by utilizing in isolation guidelines established by the Center for Disease Control (CDC). Enhanced barrier precautions should be used in conjunction with standard precautions and enhanced barrier precautions are used as an infection control intervention designed to reduce the transmission of multi drug resistant organisms (MDROs) that is proportion extends the use of personal protective equipment (PPE) and refers to the use of gown and gloves during high contact resident care activities that provide opportunities for the transfer of MDROS to staff hands and clothing enhanced barrier precautions will be applied to all residents with any of the following; wounds, indwelling medical devices, regardless colonization status, staff will be properly trained on the proper use of PPE and will be implemented while resident high contact resident care activities that require gown and glove use include dressing, bathing showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, device care ,or use of central line, urinary catheter, feeding tube, tracheostomy, ventilator and wound care.
Review of Resident R168's clinical record revealed that the resident had the diagnoses of Quadriplegia, Hemiplegia, and dysphagia (difficulty swallowing), The resident was dependent of tube feeding.
Review of Resident R168's care plan revealed "I require enhanced barrier precautions related to feeding tube dated June 24, 2025, with interventions including gloves and gown must be worn during high contact care activities, dressing, bathing, showering, transferring, providing hygiene care, changing linens, changing briefs assisting with toileting, and device care or use".
Observation of Resident 168's room door revealed no enhanced barrier signage or any indication that the resident was on any precaution.
Observation of nurse aide, Employee E13 and nurse aide, Employee E14 providing care including bathing resident
R168 and changing this resident's incontinence briefs revealed that neither Employee E13 or Employee E14 were were wearing a gown as required PPE for enhanced barrier precautions.
Interview with nurse aide, Employee E14 confirmed there was no signage of enhanced barrier precaution on the door. Nurse aide, Employee E14 employee was not aware that a gown was warranted.
Interview with licensed nurse, Employee E18 on April 22, 2025, at 12:18 p.m. confirmed no enhanced barrier precaution signage was on Residents R168's room door and on three other doors on the third-floor nursing unit. Employee E168 stated that the signs were locked in the Assistant Director of Nursing (ADON), Employee E5 's office.
Interview with ADON, Employee E5 on April 23, 2025, at 11:32 a.m. revealed that all employees are made aware of any precaution, including enhanced barrier precaution on the floor during morning meeting prior to the shift. All employees have received education of what PPE is required for enhanced barrier precaution and when all PPE must be worn. Employee E5 stated she did not know why the employees were not following the protocol and the signs alerting staff and visitors.
Review of Resident R97's clinical record revealed that Resident R97 was admitted to the facility on January 22, 2025, with current diagnoses of Infection and Inflammatory reaction due to indwelling urethral Catheter Sequela, Obstructive and Reflux Uropathy.
Review of Resident R97's physician's orders revealed an order for: Urinary Catheter: Maintain SPC (suprapubic catheter) catheter with16F 10ml balloon for Obstructive Uropathy.
Observation conducted on April 21, 2025, at 10:25AM revealed that Resident R97 was in bed with a urine bag. Further, Urine bag and tubing was observed with cloudy with red tinged residue. Further observation revealed that there was no signage for EBP (Enhanced Barrier Precaution) signage posted outside Resident R97's room.
Follow-up observation conducted on April 22, 2025, at 10:47AM revealed that nurse aide, Employee E18 was in Resident R97's room providing care to Resident R97 without a PPE (personal protective equipment).
Interview with nurse aide, Employee E18 conducted at the time of the observation confirmed that she did not use PPE and that she did not know she had to wear PPE because there was no signage outside the door.
Interview with nurse aide, Employee E19 conducted on April 22, 2025, at 10:50 AM revealed that she knows that she has to use PPE because of the sign posted outside the door. Further Employee E19 revealed that without the sign will not know that she has to wear PPE.
Interview with Infection Preventionist Employee E5 revealed that the unit managers are responsible for putting up EBP precaution).
On April 22, 2025, 9:29 a.m., during medication administration, to Resident R20, Employee E21, a Licensed Nurse, used the sphygmomanometer (an instrument for measuring blood pressure), without disinfecting it, which was used for checking blood pressure of other residents. At the time of the finding, Employee E21 confirmed the same.
On April 23, 2025, 8:59 a.m., during medication administration, to Resident R 227, Employee E23, a Registered Nurse, used the sphygmomanometer, without disinfecting it, which was used for checking blood pressure of other residents. At the time of the finding, E23 confirmed the same.
On April 23, 2025, at 9:08 a.m., review of Physician order dated June 24, 2024, for Resident R195 revealed; "Enhanced Barrier Precautions, Every Shift".
Observation on April 23, 2025, at 9:10 a.m., revealed that a Registered Nurse, Employee E23, was applying sphygmomanometer, to Resident R195 to check the resident's blood pressure. Employee E23 did not wear the PPE, even though Resident R195 was on Enhanced Barrier Precautions. The Registered Nurse, Employee E23 used the sphygmomanometer, without disinfecting it, which was used for checking blood pressure of other residents. At the time of the finding, confirmed the same with E23.
On April 23, 2025, at 9:20 a.m. a review of physician order dated March 22, 2025, for Resident R176 revealed; "Enhanced Barrier Precautions, Every Shift."
Observation on April 23, 2025, at 9:23 a.m., revealed that a Registered Nurse, Employee E23, was applying sphygmomanometer, to Resident R176 to check the resident's blood pressure. Register Nurse, Employee E23 did not wear the PPE, even though Resident R176 was on Enhanced Barrier Precautions. Registered Nurse, Employee E23 used the sphygmomanometer, without disinfecting it, which was used for checking blood pressure of other residents. At the time of the finding, confirmed the same with Registered Nurse, Employee E23.
28 Pa Code 201.14(a) Responsibility of licensee
28 Pa Code 201.18(d) Management
28 Pa Code 211.12 (d)(1)(5) Nursing services
| | Plan of Correction - To be completed: 05/28/2025
1.Enhanced barrier signed placed on R168, and R97.
2.Full house audit conducted to ensure current residents with physician orders for enhanced barrier have appropriate signage placed.
3.DON/designee re-educated nursing staff on enhanced barrier policy and procedure. DON/designee re-educated licensed nursing staff on disinfecting equipment according to infection control policy and procedure.
4.DON/designee will conduct audits daily x4 weeks, weekly x4 and monthly x4. Results will be submitted to QAPI for review and recommendations as needed.
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