FF11 483.80(a)(1)(2)(4)(e)(f):INFECTION PREVENTION & CONTROL

REGULATION: §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.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 11, 2019
Corrected date: November 6, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey the facility did not 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 the main laundry area; and for 1of 3 residents (Resident #29) reviewed for pressure ulcers. Specifically, improper infection control technique was observed during a pressure ulcer treatment observation for Resident #29. Additionally, there was no evidence of personal protective equipment (PPE) in the wash area of the laundry room, and washer and dryers were not maintained per manufacturer's guidelines. Findings include: 1) Resident #29 was admitted to facility on 5/14/18 with [DIAGNOSES REDACTED]. The 6/13/19 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment; required extensive assistance with most activities of daily living (ADL) and had one Stage 4 pressure ulcer. The facility infection control manual documented under Personal Protective Equipment (PPE) that gloves should be changed (and hands washed) between tasks and procedures on the same resident after contact with any material that may contain a high concentration of microorganisms. The 6/22/18 comprehensive care plan (CCP) documented the resident had a pressure ulcer and the wound would be free of signs and symptoms of infection. The (MONTH) 2019 treatment administration record (TAR) documented to cleanse the wound on the left buttock with normal saline, apply Santyl (removes dead tissue) topical ointment nickel thick layer to the entire wound bed including inside tunnel, pack firmly with rolled gauze damp with 1/4 strength Dakin's (antiseptic) solution every day. On 9/10/19 at 10:55 AM a treatment of [REDACTED].#22. LPN #22 gathered supplies from the treatment cart and laid them on top of the clean linen cart with no barrier between supplies and the linen cart. She applied gloves and cleansed the wound with normal saline. She did not change her gloves or perform hand hygiene and proceeded to apply the new wound dressing. During an interview with LPN #22 on 9/10/19 at 11:05 AM, she stated the expectation of the facility was to provide wound care per order on the TAR. She was aware that she did not place a barrier down or change her gloves and perform hand hygiene after cleansing the wound and prior to performing the wound treatment. She stated the wound could be contaminated. During an interview on 9/10/19 at 12:03 PM with registered nurse (RN) Unit Manager #12, she stated that the facility expectation was supplies should always be placed on a barrier when performing wound care. She stated after a wound was cleansed, hand hygiene should be perfomed and gloves should be changed. Not performing hand hygiene or changing gloves could contaminate the wound and increase the chance of infection. During an interview on 9/11/19 at 11:39 AM with Infection Control RN #40, she stated the expectation was a clean barrier should be placed, and the supplies should be placed on the barrier to keep them clean. She stated she did not understand why gloves had to be changed and hand hygiene had to be performed when cleansing the wound. 2) During an interview on 9/11/19 at 1:01 PM, the Director of Facilities stated the washers and dryers were not maintained as per the user manual, he could not find the user manuals for all the washers and dryers and he could not find a facility policy for the maintenance of the washers and dryers. During an observation in the main laundry room on 9/10/19 at 10:11 AM there was an area in the laundry room that had no personal protective equipment (PPE) available. There were no gowns or goggles observed. Laundry Room worker #41 stated that she had goggles and a gown at the sink but was unable to locate them and not sure what had happened to them. During an interview on 9/11/19 at 9:54 AM with the Director of Housekeeping, he stated that the facility expectation was that all infectious laundry was placed in red bags from the units and brought down to the laundry area. Prior to the laundry being handled the staff must put on PPE. He stated the goggles were disposable because of dry rot on the band and he did not know why they were not replaced. He stated that he had placed gowns in the area and maintenance was placing hooks so the goggles could be hung and not get misplaced. During an interview on 9/11/19 at 10:09 AM with laundry worker #41, she stated the facility expectation was that when infectious or heavily soiled laundry came down from the units was expected to carry the laundry away from her body and wear PPE. She stated she did not know what happened to the goggles or the gowns at the wash station and did not know how long they had been missing. 10NYCRR 415.19

Plan of Correction: ApprovedOctober 4, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F880 Infection Control Resident #29 is provided care and treatment for [REDACTED]. The facility has the manufacture guidelines for the washer and dryer?ÇÖs maintenance. The facility will provide maintenance to the washer and dryer per manufacture guidelines. Personal protective equipment, specifically face shields and gowns needed for the laundry room to prevent cross contamination have been replaced and are located at the sorting area. A review of other residents with pressure ulcers was conducted by the nurse managers or designee to determine if infection control policies were being maintained during wound changes. The deficiency is isolated to the resident identified on survey. A review of the laundry room was conducted by the Director of Environmental services to determine if there personal protective equipment available for staff to safely transfer soiled linen. Any missing personal protective equipment was replaced and is stored in the sorting area. A review of the policies and procedures for infection control was reviewed and revised by the Infection Control Nurse, and the Director of Nursing. In-service education will be provided to nursing for dressing changes. The Nurse educator is responsible to complete the training. The Nurse Educator is also responsible to provide an in-service education to the laundry staff on proper use of protective equipment. Infection Control Nurse is responsible to monitor the status of the infection control program, specifically proper infection control when completing a wound treatment. Additionally the infection control nurse is to work in collaboration with the Director of Environmental services in order to maintain proper infection control in the laundry. Specifically, that there is personal protective equipment available to prevent cross contamination and laundry staff are using the personal protective equipment as per policy. A Quality Assurance study was initiated for the next three months to assure residents that require a wound treatment have proper infection control techniques and that the laundry is using personal protective equipment to prevent cross contamination. The responsible party to monitor the quality assurance program is Infection Control Nurse. The threshold for compliance is 95%. Results of the study will be shared at the quality assurance meeting for review and revision as needed.