Eddy Memorial Geriatric Center
May 14, 2020 Complaint Survey

Standard Health Citations

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 14, 2020
Corrected date: June 5, 2020

Citation Details

Based on observation, interview and record review conducted during the COVID-19 Infection Control Focus Survey completed on 5/13/20, the facility did not ensure an infection prevention and control program (IPCP) designed to help prevent the development and transmission of communicable disease and infection was maintained. Specifically, the facility did not ensure hand hygiene was completed after resident care for 1 of 1 resident reviewed. Specifically, the facility did not ensure multi-resident use equipment was cleansed after use on a resident and prior to returning item to a clean area to prevent the risk cross-contamination. This is evidenced by: A policy titled Standard/Universal Precautions revised on 12/12/2019 documented hand washing shall occur regardless of whether gloves are worn, after glove removal and between resident contact. A policy titled equipment cleaning and sanitizing dated 5/8/2020, documented an oximeter (an instrument for measuring continuously the degree of oxygen saturation of the circulating blood) should be cleansed with disinfecting agent, super Sani-wipes after each use and remain on the nursing medication cart. During an observation on 5/13/20 at 10:40 AM, LPN #1 was observed with gloved hands utilizing a pulse oximeter on a resident in a common area. LPN#1 returned to the medication (med) cart, and placed the pulse oximeter on top of the med cart. LPN #1 did not remove her gloves before using the laptop, mouse, multi use pill crusher, multi-use pudding container and multi-use thickened liquid container. During an interview on 5/13/20 at 10:45 AM, LPN #1 stated she should have cleaned the pulse oximeter immediately after resident use and prior to returning this item to a clean area. LPN #1 stated after each resident contact, she should remove gloves and cleanse hands, prior to touching a clean area or multi-resident use containers. LPN #1 stated she did not clean the pulse oximeter, as she did not have sani-wipes on her med cart, but could have obtained them from a room down the hall from the med cart. LPN #1 stated it was her habit to not remove gloves and cleanse hands immediately after resident use. During an interview on 5/13/20 at 12:20 PM, the Administrator stated, the expectation was that staff would remove their gloves and cleanse their hands immediately after resident contact and prior to touching a clean area. He stated the expectation is that all multi -resident use medical devices would be cleansed after each resident use and prior to returning them to a clean area. During an interview on 5/13/20 at 2:00 PM the Director of Nursing stated LPN #1 received a full orientation, including return demonstration of hand hygiene and infection control practices. 10NYCRR415.19 (b)(2)(4)

Plan of Correction: ApprovedMay 27, 2020

Plan of correction for Infection Control 483.80 F880
Corrective actions accomplished for those residents found to have been affected by the current practice
? Resident receiving oximeter monitoring was not affected
? LPN #1 was re-educated regarding facility policies for Equipment Cleaning and Sanitizing and Standard/Universal Precautions on 5/13/20
How to identify other residents having the potential to be affected by the same practice
? All residents have the potential to be affected by the same practice. Facility protocols for COVID-19 include oximeter monitoring of all residents
? LPN #1 was re-educated regarding facility policies for Equipment Cleaning and Sanitizing and Standard/Universal Precautions on 5/13/20
? All licensed Nurses will be re-educated regarding facility policies for Equipment Cleaning and Sanitizing and Standard/Universal Precautions
What corrective action will be taken to ensure the current practice does not recur
? All licensed Nurses will be re-educated regarding facility policies for Equipment Cleaning and Sanitizing and Standard/Universal Precautions
? Competencies will be performed for all licensed Nurses to ensure compliance with process for oximeter cleaning and hand hygiene
How will the corrective actions be monitored to ensure they are taken
? 2 random Audits will be conducted each shift weekly (including weekends) for 4 weeks then 12 random audits per month for 2 months to ensure the process for oximeter cleaning has been followed and hand hygiene has been completed
? Audit results will be reported to the QAPI monthly for 3 months. Based on the results, the Committee will determine the need for continued auditing
Date to be completed by 6/5/20
Responsible person DNS