Long-Term Care Special Edition August 2021 | Page 21

places the resident at greater risk for urinary tract infection and long-term complications including bladder and renal stones , abcesses , and renal failure . Nursing homes face similar decisions with respect to feeding residents ( hand feeding versus feeding tubes ), and in monitoring and controlling residents ’ behavior ( monitoring by staff versus physical or chemical restraints ). Although antipsychotics are not appropriate for the majority of nursing home residents with dementia , nursing homes often use antipsychotics to ‘ manage ’ behavioral symptoms associated with dementia . Feeding tubes can result in complications including self-extubation , infections , aspiration , misplacement of the tube , and pain . Immobility resulting from physical restraints may increase the risk of pressure ulcers , depression , mental and physical deterioration , and mortality . Inappropriate use of antipsychotic medications may also result in mental and physical deterioration .”
Grabowski ( 2019 ) also emphasizes that 16 percent of nursing homes were found to have at least one of the most severe deficiency citations from 2000 through 2007 . These deficiency citations are for actual or potential for death or serious injury .
Risk assessment and management can guard against adverse events and poor outcomes in long-term care facilities .
In a recent presentation at the virtual annual conference of the Association for Professionals in Infection Prevention and Epidemiology ( APIC ), Marlene Fishman Wolpert , MPH , CIC , an infection preventionist at St . Joseph Health Services of RI , explained that types of risk assessment include a facility assessment ; an Infection Control Assessment and Response ( ICAR ); an all-hazard approach IP & C risk assessment ; an Infection Control Risk Assessment for Construction ( ICRA ); and a Waterborne Infection Control Risk Assessment ( WICRA ).
Wolpert says that the first step in implementing an all-hazard risk assessment is for the IP to work with the team on the facility assessment . The ICAR will then drive the all-hazard approach IP & C risk assessment , which then leads to the development of the facility ’ s antimicrobial stewardship program . In turn , this drives the written infection control program goals and priorities . The ICRA logically guides construction projects , and the WICRA guides development of the facility ’ s water-management plan .
As we know , CMS requires a risk assessment be conducted annually , and Wolpert points out that risk assessment is a common gap in nursing homes , particularly relating to management of multidrug-resistant organisms ( MDROs ), tuberculosis and influenza . Wolpert advises that for effective risk assessments , IPs should use an all-hazard approach and for each topic , think of how well staff are educated , and base your assessment on hazards during resident activities . She says to determine your resources to prevent transmission and development of infections and assign level of risk for infection occurrence and IP & C practice .
When determining the facility ’ s risk assessment score , Wolpert identifies the following factors to consider :
1 . Probability of occurrence :
• Prior infection levels
• Community frequency
• Effectiveness of prevention campaigns
2 . Impact on resident care :
• Need for new treatment
• Change in level of care or support
• Restrictions on facility access
3 . Level of harm from events :
• Past illness
• Hospital admissions
• Prior deaths
• Resident risk factors
4 . Readiness to prevent the event :
• Surveillance to detect infection
• Performance monitoring
• Vaccination rates
• Adherence to sick-leave policies
• Visitors ’ adherence to cough etiquette
• Access to supplies / PPE
• Training / competency assessments
As we have seen , having an infection preventionist ( IP ) on staff is one of the strongest safeguards for resident care . In 2015 , the federal government , through CMS , first proposed requiring each nursing home to designate one individual ( a clinician who worked at least part-time ) as the facility ’ s IP . The American Health Care Association ( AHCA ) and LeadingAge supported this requirement and advised the Administration at the time that this professional would need to devote more time to the role . They suggested that CMS allow facilities to designate one or more individuals as IPs , so these professionals could cover for each other and work together during outbreaks . Those recommendations were reflected in the final rule , issued in October 2016 , and went into effect November 2019 . APIC is also looking to advocate for one full-time IP on the long-term care premises , at a minimum , as well as ensuring that the IP be board-certified in infection prevention and control and must create a surveillance plan for the facility .
The challenge is that IPs are concerned whether they have enough hours in accordance with CMS regulations . “ CMS wants to know you are getting the job done ,” Wolpert says . To address this , Wolpert recommends that IPs in long-term care review their risk-assessment duties and priorities , checking for gaps in their facilities ’ IP & C programs . Wolpert confirms that CMS requires a designated IP who works “ at least part-time at the facility ,” and that the IP must be qualified and have specialized infection control training .
“ An IP is going to have plenty to do ,” confirms Deborah Burdsall , PhD , RN-BC , CIC , FAPIC , who also recently presented at the APIC virtual conference on an IP ’ s role during and after the pandemic . Acknowledging the IP ’ s need to pivot to a COVID-19 response , Burdsall noted that relationships developed during CDC Infection Control Infection and Response ( ICAR ) visits provided an established network that helped communication . However , long-term care facilities were severely challenged with an inadequate infection prevention and control infrastructure . She points to the fact that components of the 2016 “ Mega Rule ,” in which CMS issued final regulations to modernize and strengthen existing Medicaid managed care rules , are now being implemented , including the requirement of a formalized IP role ( F 882 ) as well as a structured focus on infection prevention and control programs ( F 880 – F 886 ).
These mandates could not come at a better time , as the top 10 citations , as of April 2021 , Burdsall pointed out , included F0880 Infection Prevention & Control . The other top nine citations were , according to LeadingAge :
● F0886 COVID-19 Testing – Residents & Staff
● F0689 Free of Accident Hazards / Supervision / Devices
● F0684 Quality of Care
www . healthcarehygienemagazine . com • aug 2021 • LTC Imperatives Special Issue
21