§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 review of clinical records, interview with residents and staff, it was determined facility did not implement infection prevention and control program for one of three residents reviewed (Resident R1)
Findings include:
Review of facility policy 'Isolation Steps: Categories of Transmission Based Precautions,' updated July 12, 2022, indicates that Enhanced Barrier Precautions expand the use of personal protective equipment (PPE) beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms (MDRO) to staff hands and clothing.
Further review of policy indicates that all residents with the following condition should use EBP's: open wounds and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy) regardless of MDRO colonization status who reside on a unit or wing where a resident known to be infected or colonized with a novel or targeted MDRO resides.
Review of Resident R1's clinical record revealed that the resident was admitted to hospice services on May 22, 2025, with the diagnosis of hemiplegia and hemiparesis (paralysis/weakness) affecting right dominant side, pressure ulcer of sacral region - stage 4 (ulcer involving loss of skin layers, exposing muscle and bone, and chronic kidney disease.
Review of Resident R1's care plan, revealed resident has pressure ulcer to sacrum, right heel and right lateral foot related to immobility , history of ulcers and thin/fragile skin. Further review of care plan revealed no evidence of interventions related to enhanced barrier precautions.
Observations of Resident R1's room, on Thursday, May 29, 2025 at 11:00 am, revealed a door post indicating Resident R1 is on EBP's.
Further observations revealed wound care treatment supplies in basins on floor; wound vacuum attached to residents sacral wound was touching the floor.
During observations of wound care treatment, completed by Wound Care Nurse, employee E1 and Physician Assistant, employee E2 , on Thursday, May 29, 2025 at 11:45 am, Employee E1 and Employee E2 did not wear gowns during procedure. Employee E1 removed wedge pillow off of Resident R1's bed and placed it on floor - then proceeded to place same wedge pillow under resident's bare back, close to opened sacral wound. Employee E1 was also observed to place the end of wound vacuum which touched floor on resident's bed pad. Further observations revealed Employee E1 changing gloves by retrieving them from her pocket.
Further observations of Resident R1's room environment revealed stale flowers on R1's bedside table attracting flies.
Findings confirmed with Employee E1, Employee E2 and Licensed nurse, Employee E3.
28 Pa. Code 211.10(c)(d) Resident care policies
28 Pa. Code 211.12(d)(5) Nursing Services
| | Plan of Correction - To be completed: 07/09/2025
No retroactive correction for this deficient practice.
The DON/Designee will audit staff for use of PPE (5) times weekly x 4 weeks and monthly x two months.
The DON/Designee will in-service all staff involved with resident care for use of PPE involving Enhanced Barrier Precautions.
The DON/Designee will audit staff for use of PPE (5) times weekly x 4 weeks and monthly x two months. Findings will be reported during monthly QAPI Meeting for further recommendations.
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