Safeguarding Residents: F880 Infection Prevention and Control

Safeguarding Residents: F880 Infection Prevention and Control

F880 Infection prevention and control is the most frequently cited deficiency for surveys conducted during FY2025, with over 3,000 violations according to Casper data. When assessing compliance with F880 surveyors are looking to validate that the facility has established an infection control program designed to provide a safe, sanitary environment that is effective in preventing and controlling the transmission of infection within the facility.

Commonly cited issues include:

• Lack of prevention of infection breaches during the following patient care practices
  • Dining assistance
  • Provision of wound care
  • Catheter care/incontinent care
  • Transmission Based Precautions (TBP)
  • Enhanced Barrier Precautions (EBP)
  • Use of PPE
  • Hand hygiene
  • Handling of linen
• Failure to sanitize equipment
  • Glucometer
  • Mechanical lifts/slings
  • Blood pressure cuffs
• Lack of policies and procedures to address waterborne illnesses
• Lack of a program for tracking and trending infections

Deficiencies may be cited at one of the four following severity levels of non-compliance:

Level 1: No Actual Harm with Potential for Minimal Harm

• • Example: Facility failed to ensure the infection prevention control program was reviewed on an annual basis.

Level 2: No Actual Harm with the Potential for Minimal Harm

• • Example: Failure to ensure staff member utilized appropriate processes for handling and storing wound care supplies with a potential for cross contamination between residents.

Level 3: Actual Harm without Immediate Jeopardy

• • Example: Failure to identify and prevent the spread of a scabies infestation that led to multiple cases throughout the facility which caused both physical and psychological harm to residents.

Level 4: Immediate Jeopardy to Resident Health or Safety

• • Failure to develop and implement an antibiotic protocol that includes the reporting of results of laboratory data to the MD that could lead to misidentification and treatment of harmful organisms resulting injury or death.

To ensure resident health and safety while complying with infection control regulations, facilities should adopt an interdisciplinary approach supported by leadership. Key focus areas should include:

• • Comprehensive policies and procedures delineating staff responsibilities regarding infection prevention, encompassing outbreak management, MDRO protocols, and evidence-based practices are key. Policies and procedures should align with updated CDC and CMS guidelines and be reviewed by facility leadership annually or as needed.
  • Staff should receive education and training on infection prevention practices, including hand hygiene, PPE use, and EBPs, at the beginning, after any policy changes, and annually. Training should incorporate competency checks. The inclusion of all staff from various departments outside of nursing including housekeeping, dietary, activities, therapy, and social service is key to systemic prevention and control of infection.
  • Accessible and adequately supplied PPE is crucial. Appropriate signage for infection-based precautions should be posted outside of resident rooms to assist with staff and visitor compliance.
  • Conduct routine monitoring, auditing, and surveillance to assess compliance with a focus on high-risk areas such as hand hygiene and PPE use.
  • Maintain supportive documentation of all infection control measures implemented, records of infection surveillance, education materials, audits, outbreak response and any corrective actions implemented.

Infection prevention and control is not only a regulatory requirement under F880, but a critical component of quality resident care. By proactively identifying risk areas, ensuring robust staff training, maintaining up-to-date policies, and engaging all departments in infection control efforts, facilities can reduce the risk of deficiencies and, more importantly, protect the health and well-being of their residents.

Next Steps! Support your Infection Preventionist’s efforts to achieve ongoing compliance with F880 by registering to join Proactive May 1-2, 2025 for a targeted virtual Infection Preventionist Workshop. Learn more and register here.

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