Long-Term Care Infection Prevention

Aligning Infection Prevention and Control With Safety Codes in Long-Term Care Facilities

By Buffy Lloyd-Krejci, DrPH, MS, CIC, LTC-CIP

This article originally appeared in the August 2023 issue of Healthcare Hygiene magazine.

For the past eight years, my team and I have worked with hundreds of long-term care facilities throughout the United States to implement infection prevention and control (IP&C) measures that simultaneously comply with Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) requirements and lower the risk of infectious disease outbreaks among residents and staff. One of the biggest barriers to achieving these goals: many times, facility staff believe IPC best practices directly conflict with life, fire, and health safety codes.

Given the frequency with which we encounter this perspective, my team and I have spent a lot of time educating ourselves about how to align IPC with survey requirements around safety codes. What we have come to realize in the course of our research is that, when implemented according to regulatory guidelines, IPC measures generally don’t contradict safety codes.

Take alcohol-based hand rub (ABHR), for example. CMS guidance states that facilities should put ABHR with 60 percent to 95 percent alcohol in every resident room (and ideally, outside of each room, as well). ABHR should also be placed in resident care and common areas.1 However, despite this guidance, the majority of facilities we work with believe they’ll get cited for violating fire safety codes if they have that amount of ABHR in their buildings.

To avoid being cited, facilities often choose to use soap and water for hand hygiene instead. However, this isn’t always a good solution: CDC and CMS guidance clearly states that, unless hands are visibly soiled, an alcohol-based hand sanitizer is preferred over soap and water in most clinical situations.2

When we dug deeper into the guidance and regulations, we discovered that fire safety codes around ABHR can be adhered to while still following CMS guidance. For example, fire safety codes require that hand rub solutions do not exceed 95 percent alcohol content by volume. The capacity of the ABHR dispensers used must not exceed 1.2 liters (41 ounces) for dispensers located in rooms, corridors, and areas open to corridors. Dispensers located in suites of rooms separated from corridors can have a 2-liter capacity (67 ounces). Furthermore, facilities can have up to 10 gallons aggregate of ABHR within a single smoke compartment (this amount is not inclusive of one dispenser per room).3

Reading through these safety codes, you can readily see that long-term care facilities should be able to easily follow CMS’s ABHR guidance while staying within fire safety code parameters.

Sometimes, facilities—particularly those with dementia units—also express concerns about residents consuming ABHR. To help mitigate this possibility, facilities can conduct an assessment to determine whether the risk of a resident getting into ABHR is greater than the risk of infections spreading because ABHR was unavailable.

If a facility determines that a resident (or residents) is likely to consume ABHR, there are solutions available other than eliminating the sanitizer altogether. For example, perhaps the dispensers can be placed higher on the wall where they’re harder for residents to easily access. If that isn’t a viable solution, staff may be able to clip small bottles of ABHR onto their uniforms or wear a small bottle of ABHR on a lanyard. Ultimately, there’s no one right answer: facilities may need to find creative ways to keep residents safe while maintaining compliance with safety codes and IP&C guidelines.

Another fear facilities commonly express is regarding cleaning microfiber mops and towels. Healthcare-grade versions of these products are highly effective at picking up dangerous microorganisms. However, these products must be dried in a dryer; if they are allowed to simply air dry, they can transfer those microorganisms to other surfaces and cause cross-contamination. Therein lies the sticking point: there are fire-associated risks with drying microfiber in a commercial clothes dryer, so many facilities opt to line dry.

To keep residents safe, the best course—and the course required by CMS—is to review and follow the Manufacturer Instructions for Use (IFUs) for laundering the textile.4 If the IFU states that the microfiber mop or towel should be dried in the dryer, facilities should begin doing so, and at the appropriate heat setting. To reduce the risk of fire, staff should inspect and clean all lint in the dryer case, exhaust pipes, and/or traps daily (this is also a life safety code).

As you can see, when it comes to ABHR and microfiber cleaning products, IP&C measures can absolutely be implemented while still maintaining compliance with life safety codes. And this pattern holds true in every aspect of IPC—by reviewing the updated guidance that surveyors are using,5 each facility’s on-site infection preventionist (IP) can ensure compliance is maintained with IPC, fire, health, and life safety codes.

There’s no question that it’s a lot to keep track of. However, at the end of the day, this truly is the best way to reduce the possibility of infection outbreaks, keep residents and staff safe, and ensure that IPC protocols—from laundry to environmental services, hand hygiene, food prep, and more—comply with safety code regulations.

Buffy Lloyd-Krejci, DrPH, CIC, LTC-CIP, is a leading authority on infection prevention in the long-term care industry. Her firm, IPCWell, delivers in-person gap analysis, training, and support to nursing homes across the country.


  1. CMS Announces New Measures to Protect Nursing Home Residents from COVID-19
  2. Ibid.
  3. Fire Safety and Alcohol-Based Hand Sanitizer (ABHS)
  4. Guidelines for Environmental Infection Control in Health-Care Facilities
  5. Nursing Homes


The Importance of Staff Education and Training in Infection Prevention and Control

By Buffy Lloyd-Krejci, DrPH, MS, CIC, LTC-CIP

This article originally appeared in the July 2023 issue of Healthcare Hygiene magazine.

For the past several years, infection prevention and control (IP&C) programs in long-term care facilities have come under increased scrutiny from a variety of governmental agencies and other groups. In November 2019, for example, just prior to the COVID-19 pandemic, the Centers for Medicare & Medicaid Services (CMS) began requiring all facilities that receive CMS funding to have, at minimum, a part-time infection preventionist (IP) onsite.1 More recently, the Biden administration has proposed minimum staffing levels for long-term care facilities,2 and the Association for Professionals in Infection Control and Epidemiology (APIC) has pushed for full-time IPs in all long-term care facilities.3

Regardless of whether these and other proposals pass, the fact remains that long-term care facilities have a responsibility to keep their residents as healthy as possible. Unfortunately, this isn’t always easy; infections are a major health risk to this vulnerable population. Many residents have comorbidities that make them especially vulnerable to infections and disease. On top of that, they live in a congregate setting, which increases the chances that infections will spread more quickly.

To counteract these threats and keep their residents safe, facilities must prioritize IP&C. The good news is that implementing effective IP&C measures does not mean facilities must take on an institutional feel. In fact, if they approach IP&C correctly, long-term care facilities can maintain a homey, comfortable feel for their residents, while still ensuring they are taking every precaution to prevent and control infections.

The best way to achieve these outcomes is to build a facility-wide culture focused on IP&C. That means all staff, including non-clinical employees, must be educated about how they can mitigate infection risk and avoid inadvertently spreading infections among residents. Environmental services staff must be trained to follow cleaning best practices.4 Food service staff need education around food prep and safety best-practices. Laundry staff must be taught what steps they should take to reduce the chances of cross-contamination.5 The list goes on; in short, because every team member at the facility—no matter their role—touches some aspect of resident care, every team member must be trained in proper IPC measures for their respective role. Team members must also be monitored to ensure they remain compliant with those standards.

If training and monitoring your staff in proper IP&C procedures feels daunting, I have a solution for you: enlist your facility’s infection preventionist. In addition to surveillance, overseeing your facility’s antibiotic stewardship program, overseeing water management, and more, your IP can educate staff in IP&C best practices and audit them to make sure they are adhering to best practices. They can also help build and foster a culture that prioritizes infection prevention and control, while simultaneously ensuring your facility maintains a home-like environment for your residents.

To be successful in these endeavors, IPs need three things. First, they must be allowed to focus fully on their IP role. Asking them to take on additional responsibilities (for example, asking them to be your director of nursing, as well) will set them up for failure in both roles. The job of infection preventionist is a big one; give them the time they need to do it properly.

Secondly, your IP needs the full support of the facility’s leadership and ownership. No matter how competent they are, without that support, it’s likely they will be pulled in other directions and/or be unable to enforce the measures they implement.

Finally, to meet all their responsibilities, IPs must be willing and able to delegate some of their tasks to other staff members. For example, we covered earlier that staff must be trained in IP&C measures, then audited to ensure they comply with those requirements. IPs can delegate those audits to department supervisors, or even train staff to audit each other. Along with freeing up time for the IP to focus on other duties, delegating in this way will help foster a culture focused on infection prevention and control throughout the facility.

When facilities ensure their IPs are supported in these three ways, a multitude of positive outcomes occur, and most importantly, infections are reduced. As a result, the facility doesn’t need as much personal protective equipment (PPE), which reduces costs. On top of that, staff are happier, families are happier, and the residents themselves are happier.

Want to replicate these outcomes in your facility? Give your IP the time, resources, and support they need to educate staff and build a culture focused on infection prevention and control. If you do, chances are high you will enjoy similar success.

Buffy Lloyd-Krejci, DrPH, CIC, LTC-CIP, is a leading authority on infection prevention in the long-term care industry. Her firm, IPCWell, delivers in-person gap analysis, training, and support to nursing homes across the country.


1. Updated Guidance for Nursing Home Resident Health and Safety
2. Biden’s nursing home staff mandates expected soon
3. APIC calls for Dedicated Infection Prevention Staff at all Long-Term Care Facilities to Prevent Deaths of Seniors
4. Best Practices for Environmental Cleaning in Healthcare Facilities
5. Linen and laundry management




Potential Solutions for Antibiotic Resistance in Long-Term Care Facilities

By Buffy Lloyd-Krejci, DrPH, MS, CIC, LTC-CIP

This article originally appeared in the June 2023 issue of Healthcare Hygiene magazine.

In September 2016, the Centers for Medicare & Medicaid Services (CMS) issued guidance requiring all licensed long-term care facilities (specifically, skilled nursing facilities) to have a fully implemented antibiotic stewardship program.1 Several years later, CMS updated and refined these guidelines by requiring every long-term care facility that participates in the Medicare and Medicaid programs to have an onsite part-time infection preventionist.2

CMS viewed these revisions as critical steps in mitigating infectious diseases—and they are. However, these guidelines do not adequately address the increasing prevalence of antibiotic resistance that has resulted from the overuse and overprescribing of antibiotics. Antibiotic resistance is a full-blown global health crisis; multi-drug resistant organisms (MRDOs) are killing people in the millions, and the crisis is only expected to get worse.

In particular, the profligate overprescribing of antibiotics is a serious threat to the health and well-being of long-term care facility residents. Research consistently shows that antibiotic prescribing practices contribute to local resistance patterns,3 which can then give rise to MRDOs. To give you a sense of the scale of this problem, consider this: in 2021, Clinical Infection Diseases published findings indicating that at least 28 percent of antibiotics prescribed are unnecessary.4 Furthermore, studies have found that up to 50 percent of all outpatient antibiotic use is inappropriate.5

There’s more bad news: bacteria develop resistance to antibiotics very quickly.6 Less than 10 years after Tetracycline was introduced, for example, antibiotic resistance to it was identified. Only two years after Methicillin became available, bacteria developed resistance to it. The same year that Levofloxacin was introduced, resistance to it was also seen. This pattern plays out over and over with devastating consequences, and to make matters worse, the Centers for Disease Control and Prevention (CDC) released a special report in 2022 that shows COVID-19 made it even harder to combat antimicrobial resistance. 7
Given that nearly 5 million people died from antimicrobial resistance in 2019 alone,8 it’s imperative that long-term care facilities take steps to move the needle forward in decreasing antibiotic resistance. There are several ways facilities can achieve this goal.

First and foremost, physicians at long-term care facilities must be far more judicious in prescribing antibiotics to residents. The importance of this cannot be overstated: it is easy to think of antibiotics as “superdrugs,” but the truth is, they are only indicated in certain instances. Far too often, however, antibiotics are the first response utilized when a resident becomes sick. It is crucial to remember that antibiotics only work for bacterial infections. They don’t work to combat viral infections and prescribing them for a virus may contribute to antibiotic resistance down the road.

Next, long-term care facilities must recognize that antibiotic resistance impacts them. Because this problem is so big, it’s often easy for facilities to dismiss it as something that is happening elsewhere. However, as the rising number of nursing home cases of the drug-resistant C. auris9 has shown, antibiotic resistance has the potential to affect long-term care facilities anywhere in the country.

Third, long-term care facilities must consistently implement and utilize antibiotic timeouts. Seventy-two hours after a resident is placed on an antibiotic, the facility should evaluate the results of the culture that was taken when that resident first showed signs of an infection. Is the culture positive for a bacterial infection? Does it indicate the need for an antibiotic? If so, has the resident been placed on the proper antibiotic? Used correctly, the antibiotic timeout can provide crucial information about the appropriate course of action (i.e., keeping the resident on the antibiotic, changing to a new antibiotic, or discontinuing antibiotic use altogether).

Long-term care facilities should also utilize a team of people to monitor appropriate antibiotic use. Their infection preventionist, for example, can use line listing and surveillance tracking in the resident’s electronic health record to ensure that antibiotics are an appropriate response to a resident’s illness. Along with the facility’s pharmacy consultant, they can also use antibiograms10 to identify and monitor local antibiotic-resistance patterns and antibiotic susceptibility. Additionally, facilities can also implement monthly antimicrobial meetings. These meetings, which help ensure the facility’s physician or nurse practitioner is prescribing appropriately, should include the facility’s infection preventionist, medical director, and pharmacy consultant.

Finally, I recommend that long-term care facilities utilize the guidance about antibiotic stewardship programs provided by the Agency for Healthcare Research and Quality (AHRQ). Indeed, whether a facility has an established antibiotic stewardship program already or is just launching it, the AHRQ’s Toolkit to Improve Antibiotic Use in Long-Term Care11 is a phenomenal resource that can help nursing homes create that all-important culture of safety around antibiotic prescribing and improve their antibiotic stewardship programs.

The bottom line is that antibiotic resistance is a serious and growing healthcare crisis. While progress to address this threat was being made leading up to 2020, the COVID-19 pandemic derailed many of those efforts. However, by following the strategies described above, long-term care facilities can help mitigate the impacts of antibiotic resistance and keep their current and future residents safe and healthy.

Buffy Lloyd-Krejci, DrPH, CIC, LTC-CIP, is a leading authority on infection prevention in the long-term care industry. Her firm, IPCWell, delivers in-person gap analysis, training, and support to nursing homes across the country.


  1. CMS finalizes improvements in care, safety, and consumer protections for long-term care facility residents
  2. Updated Guidance for Nursing Home Resident Health and Safety
  3. Outpatient antibiotic prescribing and nonsusceptible Streptococcus pneumoniae in the United States, 1996–2003
  4. Unnecessary Antibiotic Prescribing in US Ambulatory Care Settings, 2010–2015
  5. Measuring Outpatient Antibiotic Prescribing
  6. The Antibiotic Resistance Crisis, Figure 1
  7. COVID-19 & Antimicrobial Resistance
  8. National Infection & Death Estimates for Antimicrobial Resistance

Candida auris: A Drug-resistant Germ That Spreads in Healthcare Facilities

  1. What is an antibiogram?
  2. Toolkit To Improve Antibiotic Use in Long-Term Care


Staying on Top of the Latest Enhanced Barrier Precautions Recommendations for Long-term Care Facilities

By Buffy Lloyd-Krejci, DrPH, MS, CIC, LTC-CIP

This article originally appeared in the May 2023 issue of Healthcare Hygiene magazine.

There is no question that the COVID-19 global pandemic shook the long-term care industry. It may appear as though SARS-CoV-2 is the only virus that we are fighting. There are, however, ongoing devastating consequences from other infectious diseases such as multidrug-resistant organisms (MDROs). In fact, certain MDROs such as Candida auris (C. auris) have been showing up in the news quite a lot lately.

A robust infection prevention and control program includes implementing evidence-based research as provided by our public health leaders such as the Centers for Disease Control and Prevention (CDC). One such practice is using enhanced barrier precautions (EBP). This guidance has evolved over the years with the first interim guidance on July 26, 2019, recommending additional personal protective equipment (PPE) along with eliminating room restriction for preventing the transmission of novel or targeted MDROs.1 On July 2021, the CDC further published the Considerations for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities.3 This “consideration” including implementing gown and glove usage for high contact resident care activities for residents that had a wound, indwelling medical device (regardless of if they have an MDRO colonization), infection, or MDRO colonization. Finally, on July 12, 2022, the CDC published updated guidance for the Implementation of this practice.3

There has been a lot of resistance regarding the recommendations to implement this higher level of protection for residents with the two most highly voiced concerns being that it will require an exorbitant amount of PPE and that by implementing this practice, it takes away from the homelike environment for the residents.

Before we dive in, I do want to touch on how antimicrobial resistance is an urgent, global threat. Data suggests that antibiotics may be inappropriately prescribed as much as 50 percent of the time.4 The organisms that we are fighting have evolved to become resistant to antibiotics and contribute to 2.8 million antimicrobial-infections in the U.S. each year.5 In 2019, they contributed to 5 million deaths globally. So, what does this have to do with EBP?

New research demonstrates that the incidence of MDROs within long-term care may be significantly more than is documented. One study looked at residents that were documented with an MDRO and after prevalence testing, uncovered an additional 40 percent of colonized residents.6  This means that these infections are silently spreading within this healthcare setting.

Another study from the Chicago Department of Health evaluated a nursing home for the prevalence of C. auris, an emerging fungus that causes serious wound, bloodstream, respiratory, and urinary infections. Originally, one resident of 69 (1.4 percent) had a documented case of C. auris. When further prevalence testing was done, the cases of C. auris jumped to 29 (42.0 percent) of the residents having C. auris.7

These studies raise the issue of basing our prevention practices merely on documented cases. Taking this a step further, it is not appropriate to test every resident for MDROs, therefore, we must take other preventative measures. This brings us to the importance of implementing EBPs for residents who may be at high risk.

Therefore, how do we implement these new practices? The first thing I suggest is filling out the CDC’s questionnaire to determine readiness (see link below).8 This tool will assist the long-term care facility assess readiness for implementing EBP.

Next, if a facility has a resident that is high-risk (indwelling device such as a catheter, an IV, a peg tube, a ventilator, colonized with an MDRO, have a wound, or an infection when contact precautions are not required) they need to wear a gown and gloves when performing a high contact touch activities such bathing, dressing, or transferring the resident.

When a resident is on EBP, ensure there is an appropriate sign on the outside of the door (see below for a sample)9. This is key to alerting the staff on who to utilize EBP for.  Remember that residents do not have to be in a single room or stay confined to their room. Residents can even have a roommate on EBP. Simply remember not to share any PPE. Gowns and gloves are for single use only.

To keep the environment more homelike, consider placing the gown and gloves inside of the resident’s room. This is perfectly acceptable, however, if you feel that this will confuse the staff regarding donning procedures for contact precautions (prior to entering the room), then consider placing a larger PPE bin in the hallway near the resident’s room.

I cannot emphasize enough how important it is to provide ongoing education to the healthcare workers. This practice is very different than contact precautions where PPE needs to be done prior to stepping foot in the resident’s room every time. EBP isn’t as restrictive for the residents or the healthcare workers.

The success of your facility’s ability to prevent the spread of these MDROs requires a multi-layered approach which includes appropriate communication, conducting hand hygiene audits, environmental cleaning audits, and implementing EBP.  Keeping our residents and healthcare workers safe from harms and deaths due to infection is no easy task, but putting in the work, the education, and the training will have monumental positive effects immediately and, in the future, as we strive to be proud of our industry and the care it can deliver.

Buffy Lloyd-Krejci, DrPH, CIC, LTC-CIP, is a leading authority on infection prevention in the long-term care industry. Her firm, IPCWell, delivers in-person gap analysis, training, and support to nursing homes across the country.


  1. Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) | HAI | CDC
  2. Considerations for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities (cdc.gov)
  3. https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html
  4. https://www.cdc.gov/antibiotic-use/data/outpatient-prescribing/index.html#:~:text=CDC%20estimates%20that%20at%20least%2030%25%20of%20antibiotics,of%20all%20outpatient%20antibiotic%20use.%203%2C%204%2C%205
  5. https://www.cdc.gov/drugresistance/about.html
  6. High Prevalence of Multidrug-Resistant Organism Colonization in 28 Nursing Homes: An "Iceberg Effect" - PubMed (nih.gov)
  7. Regional Emergence of Candida auris in Chicago and Lessons Learned From Intensive Follow-up at 1 Ventilator-Capable Skilled Nursing Facility | Clinical Infectious Diseases | Oxford Academic (oup.com)
  8. Pre-Implementation Tool—Enhanced Barrier Precautions (EBP) (cdc.gov)
  9. enhanced barrier precautions final rev3 (cdc.gov)

Creating a Culture of Infection Prevention and Control Within Your Long-term Care Facility

By Buffy Lloyd-Krejci, DrPH, MS, CIC, LTC-CIP

This article originally appeared in the April 2023 issue of Healthcare Hygiene magazine.

It is no secret that a robust infection prevention and control (IP&C) program within a long-term care facility, aka nursing home, can literally save lives. Yet all too often, the IPC program falls on the shoulders of one individual, the infection preventionist (IP) and oftentimes, this one individual has little facility-wide support.

Recently, I was onsite in a nursing home conducting an IP&C supportive, boots-on-the-ground visit in a rural community. Let me set the stage. The IP had only been in his role for seven months with no prior IP&C or long-term care experience. Many of the leadership positions including the director of nursing (DON) and dietary manager were new. The facility employs agency nurses with a large percentage of staff traveling over two hours from a large metropolitan city. The IP took the 23-hour Centers for Disease Control and Prevention (CDC) training course1 for his training. He has no mentor and no one to guide him. The previous IPs lasted only a few months, which greatly weighed on his mind. He mentioned that he does not have the time to fully dedicate to IP&C responsibilities, as he was also the wound nurse and often called to fill in where nursing gaps exist.

As we took the tour of the facility, it was evident that he was overwhelmed. He did not realize that it was his responsibility to evaluate environmental services (breathing a sigh of relief when he learned that they were doing an excellent job), laundry, or food services. He hadn’t had the time to implement the new CDC recommendations for enhanced barrier precautions,2 had not fit-tested the staff for compliance to safely wear N-95 respirators, had not begun evaluating the appropriate prescribing of antibiotics, evaluating hand hygiene, transmission-based precautions, or safe injection practices. However, he wants to learn what to do and begin implementing these practices. He is dedicated and determined to be the best IP possible and deliver the safest care for the residents and staff.
While it makes sense to assign IP&C responsibilities to one person, every individual must implement IPC practices. From visitors, to executives, the responsibility cannot fall on the shoulders of only one individual. Yet, this is all too common the reality.

During my site visit, the IP asked me point blank, “Dr. Buffy, how do I get the staff to comply with the IPC practices? This is my greatest challenge.”
I told him that it all starts with relationships and having support from his senior leadership, i.e., the administrator and the DON. Without this support, it was going to be difficult. He told me that he goes out on the floor every day and talks with the staff, he works beside them helping with resident care. Elated, I told him he was on his way.

Next, to have a lasting I&C culture, every individual in the facility must be educated often on the best practices. Traditionally, training is conducted during new hire orientation and then annually. Consider increasing this education and providing new and fun strategies to deliver the material. One fun way to demonstrate the essential need to clean and disinfect the shared resident equipment after each use such as Hoyer lifts and vitals carts is to use washable paint and demonstrate how easily these “germs” spread.

When it comes to conducting infection prevention audits, consider encouraging the IP to delegate this task to other staff members. For example, have a certified nursing assistant (CNA) evaluate if their peers are conducting hand hygiene before and after leaving a room. The CNA is already working on the floor and can easily evaluate this practice. A simple tool such as the CDC’s ICAR hand hygiene audit tool,3 can be utilized. In the kitchen, the dietary manager can verify daily that all temperature logs are completed (and there are a lot). For environmental services (EVS), a daily cleaning log4 can be completed and provided to the EVS supervisor which in turn can be provided to the IP monthly.

Another strategy for creating a culture of infection prevention is communication. It is important that everyone within the facility has a voice and can communicate openly and honestly about concerns that they may have. This includes reporting any infections or outbreaks, as well as any lapses in infection control protocols, and supplies that they may need. This can be done through regular staff meetings, newsletters, email updates, and daily team huddles within each department. It is important that a representative from every department attends the daily stand-up meeting including the EVS and maintenance supervisors.

Simply put, now is the time to ensure that IP&C practices are integral to all our practices within long-term care and not simply a box that is checked when we have an IP onsite. Our vulnerable residents deserve to live out their days in an environment that prioritizes IPC and therefore reduces the risk of cross contamination and infectious disease outbreaks. Our staff deserve support in implementing these practices. We, as an industry, want to be better, but this starts with individuals who commit. Individuals who stick with it. Individuals who can work toward a goal and not be dissuaded by setbacks.
I believe this is possible.

Buffy Lloyd-Krejci, DrPH, CIC, LTC-CIP, is a leading authority on infection prevention in the long-term care industry. Her firm, IPCWell, delivers in-person gap analysis, training, and support to nursing homes across the country.

1. https://www.train.org/cdctrain/training_plan/3814
2. https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html
3. https://www.cdc.gov/infectioncontrol/pdf/icar/IPC-mod2-hand-hygiene-508.pdf
4. https://r.search.yahoo.com/_ylt=AwrijnOcryFkYaME1ggPxQt.;_ylu=Y29sbwNiZjEEcG9zAzUEdnRpZAMEc2VjA3Ny/RV=2/RE=1679958045/RO=10/RU=https%3a%2f%2fapic.org%2fResource_%2fTinyMceFileManager%2fAcademy%2fASC_101_resources%2fAssessment_Checklist%2fEnvironment_Checklist.doc/RK=2/RS=EUPL1xPMmXATC3UBL8dcCd03ens-


Taking a Closer Look at Long-term Care Staffing Mandates: Is It Finally Time?

By Buffy Lloyd-Krejci, DrPH, MS, CIC, LTC-CIP

This article originally appeared in the March 2023 issue of Healthcare Hygiene magazine.

Currently, the Centers for Medicare & Medicaid Services (CMS) requires long-term care facilities to have sufficient staffing to provide adequate care to residents. Unfortunately, the term “sufficient” is subjective and according to multiple studies has fallen severely short for what is needed to provide even “adequate” care. CMS has proposed new staffing mandates to require a minimum number of registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs) based on the number of residents in the facility that would ensure that residents receive a minimum of 4.1 hours of care per day. This new staffing requirement could take effect as early as this spring and has been the topic of heavy debate within the industry.

On the surface this mandate may seem like a no-brainer. Proponents argue that such mandates would ensure that residents receive the best possible care, while opponents suggest that mandates would be too expensive and could lead to unintended consequences. What does a staffing mandate really mean for our industry and is it realistic to implement in the wake of the COVID-19 pandemic?

Quite simply, in a perfect world, facilities would be able to always have enough caregivers to provide the residents with phenomenal care and attention. Without question or argument, every resident deserves this high level of quality care. Hence, a staffing mandate would be one step closer to ensuring that residents receive this care. Studies have shown that residents who receive more hours of direct care from nurses and other staff members tend to have better health outcomes, including fewer hospitalizations, and lower mortality rates.1 It’s not hard to see the merit in the equation of more caregivers = better care. By mandating minimum staffing levels, facilities would be required to ensure that residents receive the care they need and deserve.

In addition to improving health outcomes, proponents of staffing mandates suggest that such requirements would improve the quality of life for residents. With more staff members available, residents would be more likely to receive prompt attention when they need assistance with activities of daily living or other needs. This could help them maintain a higher degree of independence and dignity, which could contribute to their overall sense of well-being.

While staffing shortages are an ongoing issue within the industry, proponents of this mandate believe that requiring facility to have more staff would improve the high turnover rates. So many facilities struggle to attract and retain qualified staff members, particularly nurses. Overworked and understaffed nurses and other staff members struggle to provide high-quality care given the often unrealistic and sometimes dangerous working load, which leads to burnout and unsustainable working conditions. With a solid and strong workforce in place, staff would be better supported and their workloads more manageable thereby creating a more desirable working environment.

Despite all these positive aspects a mandate would provide, is it truly that simple? Is it realistic at this time when staffing is already at an all-time low? Opponents of staffing mandates suggest that such requirements would be too expensive for companies to implement. As we know, many facilities are already struggling financially, and mandating additional staff members could exacerbate this problem.

The higher costs associated with staffing, could lead to higher costs for residents and their families. Facilities that are required to maintain higher staffing levels may need to raise their fees to cover the additional expenses. This could make care even less affordable for individuals and families, many of whom are already struggling to pay for the care.

The financial consequences for a facility could be grave given the significantly low Medicaid reimbursement rates. This may lead to more facilities closing which could lead to a shortage of nursing home beds in some areas, potentially making it more difficult for individuals and families to find suitable care options. New York state is currently experiencing the consequences of a minimum staffing requirement of 3.5 resident hours per day2, which is leading to families finding it harder to place their loved ones in a facility of choice. It is further creating a bottleneck for hospitals as patients are having to wait longer for a post-acute bed, thereby delaying critical medical care services for those in need.

There already exist a shortages of nursing staff given the consequences of the COVID-19 pandemic. Therefore, where are facilities going to get staff? They may have to continue investing in agency nurses who are far more expensive, may not be as invested in the residents, and do not provide continuity in resident care.
This debate is a complex one, with both pros and cons to consider. While on paper and what research studies have demonstrated, minimum staffing requirements seem simple and the solution that is needed. I will be the first to say that the staffing levels we now have are not sufficient. I see it every day when I go onsite into facilities across the country. I see worn out staff that are exhausted and burned out with their unrealistic workloads. They need help. They deserve it and the residents deserve high quality of care. So, let’s take the pros and cons and use them to roll out staffing requirements over time that will support not collapse this already fractured system.

Buffy Lloyd-Krejci, DrPH, CIC, LTC-CIP, is a leading authority on infection prevention in the long-term care industry. Her firm, IPCWell, delivers in-person gap analysis, training, and support to nursing homes across the country.

1. Nursing Home Staffing Standards in State Statutes and Regulations. National Conference of State Legislatures. 2019.
2. Stulick, A. (2023, January 27). Skilled Nursing News. Retrieved from https://skillednursingnews.com/2023/01/cautionary-tale-staffing-mandate-collides-with-nursing-home-labor-crisis-and-referral-bottleneck/#:~:text=The%20rule%20applies%20to%20certified%20nursing%20assistants%20%28CNAs%29%2C,must%20be%20provided%20by%20an%20


Supporting the Long-term Care Infection Preventionist in a Post-Pandemic World

By Buffy Lloyd-Krejci, DrPH, MS, CIC, LTC-CIP

This article originally appeared in the February 2023 issue of Healthcare Hygiene magazine.

Prior to the global COVID-19 pandemic disrupting our lives in 2020, infections in long-term care ran rampant. In fact, the Centers for Disease Control and Prevention (CDC) reported that there were 1 million to 3 million infections within this healthcare sector annually. Worse, was that these serious infections led to 380,000 deaths.1 This is more than 1,000 people dying every single day due to infections. Furthermore, infections are the most frequent cause of transfers and hospital readmissions in long-term care, with many of them preventable.10 COVID-19 has further contributed to nearly 3 million infections and 165,000 resident and healthcare worker deaths.2 If there is a silver lining to the last three years, I would say that infection prevention and control has been highlighted as a much-needed focus area within this vulnerable population. One critical piece to mitigating infections is having educated and trained staff that are dedicated to the infection prevention and control program.

In November 2019, the Centers for Medicare and Medicaid Services (CMS) required all certified nursing homes to have at least a part-time dedicated infection preventionist (IP) on staff. The CDC recommends that a facility have “at least” one full-time infection preventionist with a facility that has more than 100 residents.5 California Department of Public Health (CDPH) has taken things one step further and requires every facility to have a full-time IP.6

IPs have numerous important duties such as identifying patterns of infections, educating staff members, residents, and families, conducting surveillance and analysis, evaluating antibiotic prescribing practices, and more.3 They have a critical role to fill, yet challenges abound. Long-term care facilities are wounded and struggling to fill this role, with the industry losing about 15 percent of its workforce or 238,000 staff members since the start of the pandemic.4 The burnout from the pandemic, low wages/benefits, and poor treatment of staff may have caused many to leave the industry, which is placing comprehensive infection prevention practices on the backburner for some facilities.

Fortunately, recent legislation allows for more qualified professionals to meet the requirements for the IP role.7 This legislation allows professionals that are a “licensed nurse, medical technologist, microbiologist, epidemiologist, public health professional, or other healthcare related field” to be qualified for the IP role in a SNF. This will hopefully invite more qualified individuals to enter the profession and ensure appropriate infection prevention practices are being followed and promoted.

What about the IPs themselves? Are they being supported and equipped to appropriately perform their job? Frequently when I am talking to IP’s, I am told that they are the IP on “paper only.” That the role of IP comes secondary to any other priority. They often have another role such as the assistant director of nursing (ADON) or director of nursing (DON) which leaves very little time, if any, for infection prevention practices.

One IP recently told me that she was constantly pulled to fill in elsewhere, often the med cart. She was “never able to get caught up on infection prevention and control duties.” This left the facility in a “control-only” position, not allowing for any “prevention.” We must consider the harm that this is posing for residents and the healthcare team. Consider what is contributing to staff burnout. Part of it is having to work twice as hard for residents that are on transmission-based precautions for infections. Therefore, if we prevent infections from occurring in the first place, this could reduce staff burnout and turnover.

We must also prioritize education and training for the IPs. A good starting point is with the CDC’s long-term care infection preventionist training course.8 CMS state and federal surveyors will want to ensure that the IP has the appropriate training and has gone through this or a similar training, ensuring the facility meets this regulatory requirement.

This foundational training is only the beginning of education for the IP. The Association for Professionals in Infection Control and Epidemiology (APIC) has recently created a specialized certification for long-term care infection prevention (LTC-CIP) similar to the CIC certification for acute-care facilities.9 Obtaining this certification will strengthen their IPC knowledge base and set them apart as the specialized professionals that they are. This exam application will open on Feb. 1, 2023.

While California has been able to implement the requirement of having a full-time infection preventionist, some other states are unable to enact such a “strict” protocol. As indicated, some alternatives to ensuring there is proper infection prevention occurring in facilities include: the hiring of healthcare professionals other than a registered nurse or having an IP team that consists of the designated IP, ADON, DON, and unit managers, where the duties are spread among the team. The guidelines and protocols are never static, so ongoing training and education is key.

While the industry has taken steps in the right direction, and each facility differs in its level of commitment to a robust IP&C program, generally this area of care is one that needs highlighting. As long as infection prevention is on the back burner, we will still be in control mode. Control mode often invokes the imagery of ‘scrambling to catch up, to contain.’ We mustn’t perpetually curb the flood with sandbags – we must build the dams. The difference will be measured in lives.

Buffy Lloyd-Krejci, DrPH, CIC, is a leading authority on infection prevention in the long-term care industry. Her firm, IPCWell, delivers in-person gap analysis, training, and support to nursing homes across the country.

1. https://www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/resources/guides/infection-prevent.html
2. https://data.cms.gov/covid-19/covid-19-nursing-home-data
3. https://apic.org/monthly_alerts/who-are-infection-preventionists/
4. https://medicareadvocacy.org/all-time-low-nursing-home-staffing/
5. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html
6. http://publichealth.lacounty.gov/acd/ncorona2019/healthfacilities/snf/IPP/
7. https://www.hansonbridgett.com/Publications/articles/220204-5100-infection-preventionist
8. https://www.train.org/cdctrain/training_plan/3814
9. https://www.cbic.org/CBIC/Long-term-care-certification.htm
10. https://www.cdc.gov/nhsn/pdfs/training/2017/Bell_March20.pdf


Staying Safe During the Triple Threat Season: Influenza, RSV, & COVID-19

By Buffy Lloyd-Krejci, DrPH, MS, CIC, LTC-CIP

This article originally appeared in the January 2023 issue of Healthcare Hygiene magazine.

Just when we thought we were getting our head above water with the COVID-19 pandemic, a triple threat emerges -- a “Triple-demic.” Healthcare providers are seeing higher cases of all three: Respiratory syncytial virus Infection (RSV), influenza, and COVID-19.

In long-term care facilities these viruses can live and spread extremely quickly if proper infection prevention and control practices (IP&C) aren’t adhered to. As this is an already vulnerable population, extra robust IP&C protocols will literally save lives. As infection preventionist, we too are already seeing massive outbreaks of these viruses take hold in long-term care facilities.

The mitigation strategy is different for each virus and worth taking a deeper look into the Centers for Disease Control and Prevention (CDC)’s guidance and recommendations. RSV (https://www.cdc.gov/rsv/index.html) is a common respiratory virus that usually causes mild, cold-like symptoms. It’s typically associated with children, yet this year it is wreaking havoc in our long-term care facilities with the elderly population. Adults will typically have mild symptoms or no symptoms at all, however, severe symptoms can occur with lower respiratory tract infections such as pneumonia.

Unfortunately, the CDC has very little information for infection prevention in long-term care related to RSV. Guidance on how long to keep a resident on transmission-based precautions simply unavailable. The CDC guidance (https://www.cdc.gov/rsv/about/transmission.html) does state that an individual with RSV is usually contagious for three to eight days and may become contagious a day or two before they start to show signs of illness. It also states that RSV can survive for many hours on hard surfaces. The CDC’s isolation guidelines (https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf) state that contact plus standard (not droplet) precautions should be used and the routine use of goggles is not necessary. Something very different from the way we respond to COVID-19. Given that the virus remains on surfaces for several hours, it is imperative to increase cleaning protocols for frequently touched surfaces.

Thankfully there is more guidance to follow when it comes to influenza. According to the CDC, all residents should receive the inactivated influenza vaccine annually before influenza season, although it is still appropriate to receive the vaccine after the season has commenced. Continue to adhere to Standard Precautions (https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html#a) for the care of all residents, regardless if there is a suspected or confirmed presence of Influenza. Droplet Precautions (adding the mask and eye protection) (https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html#5 ) are indicated for residents with suspected or confirmed influenza for seven days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer. Remember to post the appropriate signage (https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html) outside of the residents door to indicate to the staff and visitors what type of precautions are needed. This will greatly reduce the risk of unintended exposure. Other infection control practices to prevent influenza can include cohorting ill residents, screening employees and visitors for illness, furloughing ill healthcare personnel, and discouraging ill visitors from entering the facility.

You probably know the protocols to mitigate COVID-19 (https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html) like the back of your hand, however, it is worth a review given the ever-evolving guidance. Anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for SARS-CoV-2 as soon as possible. If you are in an outbreak, facilities may consider designating an entire unit to care for residents that are infected. This may include dedicated healthcare workers. This may, of course not be possible given staffing shortages. If these CDC recommendations are not feasible, sheltering the residents in place with the door closed is the next best option. Try to avoid unnecessarily moving infected residents around the facility as this may increase the risk for facility wide exposure. The guidance for PPE while caring for suspected or confirmed residents with SARS-CoV-2 infection has remained consistent. All healthcare personnel entering the room should wear a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection. Once leaving the room, all PPE should be discarded. Since our supply chains have been restored, there is no need to reuse any PPE as this increases the risk of transmitting the virus to the healthcare personnel. Remember, it is a requirement of the Occupational Health & Safety Administration (OSHA) (https://www.osha.gov/sites/default/files/respiratory-protection-covid19-long-term-care.pdf) for all individuals wearing an N-95 respirator to have been appropriately fit-tested which includes an annual assessment.

The CDC has announced that long-term care facilities will soon be receiving single dose COVID-19 vaccinations to administer to residents and staff. Facilities can sign up at the CDC COVID-19 Sub-Provider Vaccine Agreement for LTCF (https://protect-ows.hhs.gov/secure-upload/forms/hiffl4creafa4uk4qpvorelbns?cm_ven=ExactTarget&cm_cat=White+House+Releases+Winter+Playbook+for+LTC&cm_pla=Marks+Memos+2022+List&cm_ite=CDC+COVID-19+Sub-Provider+Vaccine+Agreement+for+LTCF&cm_lm=1384325246&cm_ainfo=&&&&& ) located on the CDC website.

Data overwhelmingly conveys that the risk for hospitalization and death are dramatically decreased with COVID-19 vaccinations (https://covid.cdc.gov/covid-data-tracker/#rates-by-vaccine-status). Continue to provide education and offer these invaluable vaccinations to your vulnerable resident population and staff.

While it may seem daunting to have these viruses circulating this season, it is important to remember prevention over reaction. Preventing the spread of these viruses is the most important step in ensuring the safety of residents and staff in the long-term care industry and any healthcare setting. Please visit the CDC website or review the CMS guidelines to ensure the appropriate prevention actions are being adhered to.

Buffy Lloyd-Krejci, DrPH, CIC, is a leading authority on infection prevention in the long-term care industry. Her firm, IPCWell, delivers in-person gap analysis, training, and support to nursing homes across the country.


Antibiotic Stewardship in the Long-Term Care Arena


This column originally appeared in the June 2022 issue of Healthcare Hygiene magazine.

We have been hearing about antibiotic stewardship for many years. Alexander Fleming, a Nobel Prize winner who discovered penicillin in 1928 (released to public in 1941) warned of the misuse of penicillin in his Nobel lecture of 1945. He stated, “It is not difficult to make microbes resistant to penicillin in the laboratory by exposing them to concentrations not sufficient to kill them, and the same thing has occasionally happened in the body. The time may come when penicillin can be bought by anyone in the shops. Then there is the danger that the ignorant man may easily under-dose himself and by exposing his microbes to non-lethal quantities of the drug make them resistant.”

The first systemic assessment of antibiotic use was completed in 1966 in a general hospital in Winnipeg, Manitoba, Canada. As early as 1968 it was estimated that 50 percent of antimicrobial use was either inappropriate or unnecessary (referenced as late as 2015). In the 1970s the first formal evaluation of antibiotic use in children regarding antibiotic choice, dose and necessity of treatment was undertaken at The Children's Hospital of Winnipeg. This study found an error rate in therapy orders to be 30 percent and 63 percent in surgical orders – with the most common error being unnecessary treatment (13 percent in medical and 45 percent of surgical orders).

During the 1980s, infection control programs began to be established in hospitals, who systematically recorded and investigated hospital-acquired infections. Evidence-based treatment guidelines and regulation of antibiotic use surfaced. Australian researchers published the first medical guideline outcomes research.

In the 1990s, antibiotic stewardship was first used, and monitoring antibiotic use and tracking outcomes was suggested. In 1997, the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) published guidelines to prevent antimicrobial resistance.

As time went on, there came a stronger push to use antibiotics appropriately. In 2012, SHEA, IDSA and Pediatric Infectious Diseases (PIDS) published a joint policy statement on antibiotic stewardship. In 2014, the CDC recommended that all U.S. hospitals have an antibiotic stewardship program.

The SNF Rules of Participation outline a regulation that all nursing homes must implement an antibiotic stewardship program by Nov. 28, 2017.

The obvious distinction between hospitals and nursing homes is we are regulated to develop and implement an Antibiotic Stewardship program. Even with the regulation, creating an environment that will encourage and sustain an antibiotic stewardship program takes much effort and continuous support. Nursing homes, also through regulation, must have an infection preventionist on staff.

Although we have known for almost 77 years that inappropriate use of antibiotics can cause resistance, we still haven’t embraced the idea wholeheartedly. Even today, an article was written that stated 70 percent of primary physicians would order antibiotics for patients who are asymptomatic when there is bacteriuria present. (Not meeting the standard criteria for a UTI.) If this occurs and the facility isn’t focused on the principles of antibiotic stewardship (meeting the infection criteria; Loeb’s or McGeer’s) the program is not very successful in its goal of utilizing antibiotics only when appropriate in order to stem the occurrence of antibiotic resistance.

The leadership in a facility is key to creating and sustaining the climate of antibiotic stewardship by holding its staff accountable. This includes the physicians and physician extenders. This takes buy in, passion, support, resources and recognition of the value that antibiotic stewardship can bring to the residents, the staff and the community.

According to the survey deficiencies issued over the past two years, long-term care must show increased progress before we can state we are committed to antibiotic stewardship. However, I do believe we have started and are inching our way along given all the other hurdles we are currently facing, such as staffing, resources and the pandemic/post-pandemic era.
We will get past these hurdles. Our residents are depending on us, as are the communities in which we reside. This is not just about long-term care but about all of us. Antibiotics used inappropriately will affect everyone not just the person receiving it.

Cindy Fronning, RN, GERO-BC, IP-BC, AS-BC, RAC-CT, CDONA, FACDONA, ELFA, is a master trainer and the director of education for NADONA.

1. https://www.reactgroup.org/antibiotic-resistance/course-antibiotic-resistance-the-silent-tsunami/part-1/the-discovery-of-antibiotics/
2. Ruedy, J. (1966). A method of determining patterns of use of antibacterial drugs. Can Med Assoc J. 95 (16): 807–12. PMC 1935763. PMID 5928520.
3. Reimann; D’Ambola (1968). Cost of antimicrobial drugs in a hospital. JAMA. 205 (7): 537. doi:10.1001/jama.205.7.537. PMID 5695313
4. Schollenberg, E.; Albritton WL (1980). Antibiotic misuse in a pediatric teaching hospital. Can Med Assoc J. 122 (1): 49–52. PMC 1801611. PMID 7363195.
5. McGowan, JE Jr; Gerding, DN (August 1996). Does antibiotic restriction prevent resistance? New Horizon. 4 (3): 370–6. PMID 8856755.
6. Shlaes, D; et al. (April 1997). Guidelines for the prevention of antimicrobial resistance in hospitals. Infect Control Hosp Epidemiol. 18 (4): 275–91. doi:10.2307/30141215. JSTOR 30141215. PMID 9131374.
7. Society for Healthcare Epidemiology of America; Infectious Diseases Society of America; Pediatric Infectious Diseases Society (April 2012). Policy statement on antimicrobial stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS). Infect Control Hosp Epidemiol. 33 (4): 322–7. doi:10.1086/665010. PMID 22418625.
8. Loria A. Pollack, Arjun Srinivasan (2014). Core Elements of Hospital Antibiotic Stewardship Programs From the Centers for Disease Control and Prevention. Clin Infect Dis. 59 (suppl 3): S97–S100. doi:10.1093/cid/ciu542. PMC 6521960. PMID 25261548.

Normalizing Deviant Behavior in Healthcare


This column originally appeared in the May 2022 issue of Healthcare Hygiene magazine.

When I first heard the term “normalization of deviance” my first thought was “What are they talking about?” As I continued to research the topic it became much clearer, and I found that it truly is something to which we in healthcare need to pay attention.

Diane Vaughan, a sociologist and a professor at Columbia University, used this phrase when describing the Challenger disaster. She found that the underlying cause of the space shuttle tragedy was related to the decision to continue to fly the space shuttle with a known design flaw of the O-rings.

Wikipedia describes the phrase of normalization of deviance as a term used by Vaughan to describe the process in which deviance from correct or proper behavior becomes normalized in a corporate culture. Vaughan defines this as a process where a clearly unsafe practice comes to be considered normal if it does not immediately cause a catastrophe: "a long incubation period [before a final disaster] with early warning signs that were either misinterpreted, ignored or missed completely."

When putting this into the healthcare perspective, how would this phenomenon happen? What would it look like?
The American Society for Healthcare Risk Management (ASHRM) states on a safety tip sheet that “Normalization of deviance is the gradual process of deviating from standard operating procedure (SOP) for various reasons and the deviation becomes the norm as no immediate adverse outcomes occur. Normalization of deviance in patient care has the potential for devastating outcomes. It plays a unique role in health care as the very safety practices and a larger culture of safety meant to prevent deviation from SOP are not as widespread as early patient safety movement proponents anticipated.”

So, again, I asked myself, what would this look like?

Not gowning when appropriate, improper application or failing to replace gloves, failing to confirm resident identify and using unapproved abbreviations are common deviations in healthcare. It can start small and can easily become the norm as more staff members do it and then mentor and train new staff. It doesn’t seem like a rule violation. Some might not even know there is a rule. It seems harmless to those involved.

Consider hand hygiene in a nursing home. For years we have had rules regarding when hand hygiene should be performed, how to perform it, and what soaps or alcohol-based handrubs (ABHRs) should be used. Many facilities have perfect policies and procedures written, which provide this information to the staff who are directed to follow them. However, in many facilities there was a lack of sinks or not enough ABHR stations or dispensers. Individual containers were not readily available or even supplied at all. Nurses started taking short cuts, justifying it by thinking: “I wash my hands after I take my gloves off but not always before I put them on.” “I wash my hands when I go into a room but not always before I leave.” “I use ABHR but I don’t always wash my hands with soap and water when I have taken care of someone with C. difficile.”
The shortcuts take on a life of their own and if not recognized as poor practice and identified as a deviant practice; without some kind of outcome or penalty, the practice continues. It is a slow incubation period and until a tragedy occurs or a significant outcome is experienced, it continues to happen.

Let’s move now into the post-COVID era of our lives. How many of those nurses in those first several days and weeks were practicing hand hygiene in the manner that they had for the past months and years? What if some of those residents that contracted COVID-19 or some of the staff that became infected did so because of that negligent practice? How many infections could have been avoided by auditing and providing remedies for the poor performance prior to this pandemic?

Another example of this is described by John Banja in a paper, “The Normalization of Deviance in Healthcare Delivery.” The story was relayed to him by another physician: “When I was a third-year medical student, I was observing what turned into a very difficult surgery. About two hours into it and after experiencing a series of frustrations, the surgeon inadvertently touched the tip of the instrument he was using to his plastic face mask. Instead of him requesting or being offered a sterile replacement, he just froze for a few seconds while everyone else in the operating room stared at him. The surgeon then continued operating. Five minutes later he did it again and still no one did anything. I was very puzzled, but when I asked one of the nurses about it after the operation, she said, ‘Oh, no big deal. We’ll just load the patient with antibiotics, and he’ll do fine.’ And, in fact, that is what happened; the patient recovered nicely.”
What about the next time? What about the patient having to receive antibiotics that might not have been needed if the physician had practiced appropriate infection prevention procedures? What if someone had spoken up? What if the patient developed C. difficile from the antibiotics?

When questioned about these deviant practices some common responses have been:
• “The rules are stupid and inefficient”
• “Knowledge is imperfect and uneven”
• “Knowing rules, guidelines, why does the guideline exist?”
• “How many rules or checklists are you expected to know in your daily practice?”
• “I’m breaking the rule for the good of my patient”
• “Workers are afraid to speak up”
• “The rules don’t apply to me/you can trust me”
• “Leadership is withholding or diluting findings on system problems”

We, as an industry, have an obligation to our residents and our staff to speak up and recognize these practices for what they are: noncompliance and a disaster in the making.

We need to make some changes to stop this from occurring and bring us back to the place of following the rules that provide both residents and staff with the best safety possible. How do we do that?

Again, it must be a priority, something for which we are on the alert. Currently, you would stop a staff person from stepping into a transmission precaution room with a resident with COVID, from entering without PPE. We need to be on the alert with not only the big items but the small things as well.

Here are some ways to accomplish this:
• Conducting audits for various practices – This could be shared between the director of nursing (DON), infection preventionist, nurse, nurse educator, environmental services, dietary, etc.
• Creating a no-blame culture where the staff member isn’t blamed, but the system goes under review (such as not having ABHR available). Developing a culture where staff feel comfortable speaking up and sharing as well as intervening when seeing those process deviations.
• Talk to staff and get their feedback about procedures that are found not to be in compliance. Do a deep dive to find out why they are taking shortcuts.
• Take the time to review a practice and see if it needs updating. Test it out and get suggestions on how to prevent those short cuts from occurring.
Paying attention to details like incident reports, audits and feedback will help us. Together they can direct us on how to proceed. This is an excellent project for QAPI. It calls for identifying the issue, doing a root cause analysis, creating some interventions, and then trying them out.

We can’t be overly optimistic that we can fix it quickly but with determination and resolve we can whittle away and in time prevent the next “catastrophe” from happening.

Cindy Fronning, RN, GERO-BC, IP-BC, AS-BC, RAC-CT, CDONA, FACDONA, is a master trainer and director of education for the National Association of Directors of Nursing Administration in Long-Term Care (NADONA).


The Normalization of Deviance in Healthcare Delivery


The Normalization of Deviance in Healthcare Delivery


Exploring Enhanced Barrier Precautions


This column originally appeared in the October 2021 issue of Healthcare Hygiene magazine.

The title of this article raises some good questions. What are enhanced barrier precautions? Where do they fit when considering Standard Precautions and Transmission-based Precautions? How long have they been in effect?

In the past several weeks, it has become apparent that many facilities across the nation are unaware of these precautions. With the COVID-19 pandemic starting shortly after the effective date of this guidance, it is plausible that it got lost in the shuffle of many new requirements and rules and reporting mandates as well as the number of residents with the infection, shortage of staff and lack of personal protective equipment (PPE). However, these enhanced barrier precautions are an important ingredient to stopping the spread of multidrug-resistant organisms (MDROs), so it seems prudent to discuss it.

As of July 2019, novel or targeted MDROs included:
• Pan-resistant organisms
• Carbapenemase-producing Enterobacterales
• Carbapenemase-producing Pseudomonas spp.
• Carbapenemase-producing Acinetobacter baumannii
• Candida auris

In an interview of Kara Jacobs Slifka, MD, MPH, and Nimalie Stone, MD, MS, physicians with the long-term care team in the Prevention and Response Branch within CDC’s Division of Healthcare Quality Promotion, addressed why MDROs pose such a threat in nursing homes, even more than in other healthcare facilities, They stated, “MDROs, especially those for which we have limited antibiotic treatment options, pose a threat in healthcare because they colonize individuals for prolonged periods of time, silently spread, and cause invasive infections with high morbidity and mortality. As healthcare delivery keeps shifting away from hospitals, nursing homes are providing more care to medically complex and frail individuals who are more vulnerable to the harms from MDROs. The combination of the long lengths of stay, exposures to indwelling medical devices and antibiotics, and the increased dependence of nursing home residents contribute to the spread and acquisition in this setting.”1

Let’s examine the evolution of precautions to see how we got here.

Infection precautions of some sort have been used since the 14th century when ships were quarantined for 40 days out at sea to prevent the spread of the plague. By the early 1900s, some elementary practices were in place by using barrier gowns and the start of antisepsis such as handwashing and disinfection had begun. This was known as “barrier nursing.” It wasn’t until 1970 that published guidelines were introduced and used. Throughout the rest of the 20th century and the early years of the 21st century, the guidelines changed and in 2019 enhanced barrier precautions were introduced. The COVID -19 pandemic brought home the need for diligent use of precautions and PPE. For this journey through the changes, see Table 1.

Using contact precautions often is a balancing act between preventing MDRO transmission and residents’ quality of life. Use of PPE and room restrictions leads to residents being isolated from staff and family and causes depression and physical function decline as witnessed during the current pandemic.

CDC states, “Focusing only on residents with active infection fails to address the continued risk of transmission from residents with MDRO colonization, which can persist for long periods of time (e.g., months), and result in the silent spread of MDROs.”2

CDC indicates there is growing evidence that using Contract Precautions in the current manner isn’t adequate to prevent MDRO spread.

Implementation of enhanced barrier precautions is in the middle between Standard Precautions and Contact Precautions. PPE is used in certain circumstances but doesn’t require the resident to be restricted to their rooms, thus providing the goal of reducing MDRO spread while maintaining residents’ quality of life.

Perhaps to put enhanced precautions into some perspective we should discuss Standard and Contact Precautions.
Standard Precautions, as indicated earlier in Table 1, are infection prevention practices that are used when caring for all residents regardless of infection or colonization status. These practices are based on the premise that all body, blood fluids, secretions and excretions (except sweat) may contain infectious pathogens that are transmissible. Proper PPE, hand hygiene, safe infection practices, respiratory hygiene and cough etiquette, environmental cleaning and disinfection, and disinfection of point of care equipment.

Contact Precautions are one of the Transmission-based Precautions that are used to prevent the spread of infectious pathogens that are spread via direct and indirect contact from the resident or resident environment. It requires the resident to remain in their room and are restricted from group activities. It is usually a short-term intervention and should have a planned discontinuation such as when symptoms are not evident or other criteria has been met.

Enhanced barrier precautions became effective on July 26, 2019. The interim guidance was updated and posted on that date. This update does not replace the existing Contact Precautions nor is it intended for acute-care or long-term care hospitals. It expands the use of PPE beyond Standard Precautions and calls for the use of gloves and gowns during high-contact activities where MDROs might be transferred to staff hands and clothes. This includes residents that are infected or colonized when Contact Precautions don’t apply.

Only the following high-contact resident-care activities are included in these precautions and require the wearing of gloves and gowns:
• Dressing
• Bathing/showering
• Transferring
• Providing hygiene
• Changing linens
• Changing briefs or assisting with toileting
• Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator
• Wound care: any skin opening requiring a dressing3

Other resident care does not require these precautions unless indicated by Standard Precautions. Residents are free to come and go from their rooms. See Table 2 for a breakdown of the three precautions.
Table 2: Summary of PPE Use and Room Restriction When Caring for Residents Colonized or Infected with Novel or Targeted MDROs in Nursing Homes4

So, now you might be asking, how do I implement this guidance? There are six steps to using these precautions and they also apply to Contact Precautions. The most important factor is to ensure that staff are aware of the facility’s expectations regarding these precautions.
1. Signage: Be sure you have proper signs posted on the resident’s door or wall next to the door regarding the precaution. It should indicate the PPE required and for Enhanced Barrier Precaution it should Indicate which high contact activities require the PPE.
2. PPE: Critical to have appropriate and adequate PPE supplies outside the room.
3. Alcohol-based handrub (ABHR): Access to ABHR both inside and outside the room is preferable.
4. Trash can: Location of a trash can just inside the resident’s room door to allow for PPE removal.
5. Monitoring and assessment: To ensure that staff are following the policies and procedures for these precautions and to determine if additional education is needed. This can be random, under cover and planned/scheduled.
6. Education: Provide residents and family members with education and training opportunities on these precautions and why they are necessary.

Prevention of MDRO transmission in nursing homes requires more than just proper use of PPE and room restriction. Education, training, and monitoring is also needed to ensure the implementation of other recommended infection prevention practices (such as hand hygiene, environmental cleaning, proper handling of wounds, treatment of indwelling medical devices, and disinfecting of resident-care equipment) are occurring appropriately.

Cindy Fronning, RN-BC, CDONA, FACDONA, RAC-CT, IP-BC, AS-BC, is the director of education at NADONA. She was a national consultant for more than 20 years and developed and teaches the infection prevention and control certificate of mastery and antibiotic stewardship certificate of mastery courses.


1. https://www.infectioncontroltoday.com/view/enhanced-barrier-precautions-new-approach-preventing-spread-multidrug-resistant-organisms-nursing

2. https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html
3. https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html
4. https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html
5. https://www.infectioncontroltoday.com/view/enhanced-barrier-precautions-new-approach-preventing-spread-multidrug-resistant-organisms-nursing



The Long-Term Care Perspective


Editor's note: This column originally appeared in the June 2021 issue of Healthcare Hygiene magazine.

Recently I had a facility ask what the Occupational Health and Safety Administration (OSHA) had to do with nursing homes. She had been asked for a bloodborne pathogen (BBP) plan and didn’t have one. She was of the opinion that she didn’t need one since her facility was a nursing home and not a hospital or industry-driven organization.

First, some history. OSHA was established under the Occupational Safety and Health Act of 1970. It was created to ensure safe and healthful working conditions for workers by setting and enforcing standards and by providing training, outreach, education and assistance.

The Occupational Exposure to Blood Borne Pathogens Standard, § 1910.1030(d)(3) (56 FR 64175) published in 1991, protects workers who can reasonably be anticipated to contact blood or other potentially infectious material (OPIM) as a result of performing their job duties. This applies to any employer with this potential -- hospitals, post-acute facilities, freestanding labs, etc.

The Centers for Disease Control and Prevention (CDC) estimates that 5.6 million workers in the healthcare industry and related occupations are at risk of occupational exposure to bloodborne pathogens, including human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and others. All occupational exposure to blood or other potentially infectious materials (OPIM) places workers at risk for infection from bloodborne pathogens.

Other potentially infectious materials include other body fluids such as semen, vaginal secretions, cerebrospinal fluid and saliva to name a few.

In the years following the BBP standard’s publication, the CDC found that nearly 600,000 percutaneous injuries were sustained by healthcare workers annually involving contaminated sharps. Due to the concern over these exposures and the technological developments which can improve employee protection, the Needlestick Safety and Prevention Act was passed in 2000 which directed OSHA to revise the BBP Standard, requiring employers to identify and make use of effective and safer medical devices. This revision was effective April of 2001.

So, what does this mean for long-term care facilities? The BBP standard must be followed. The BBP plan must have these components:

A written exposure plan to eliminate or minimize exposures that identifies which job classifications are at risk, together with a list of task/procedures that might result in an exposure.
The plan must be updated annually to reflect the following:
• Changes in tasks /procedures
• Positions
• Technological changes that might eliminate or reduce exposure
• Use of safer medical devices
• Document solicited input from frontline workers in identifying, evaluating and selecting effective engineering and work practice controls.
• Implementation of standard precautions.

Identify and use engineering controls such as sharps disposal containers, self-sheathing needles and sharps with engineered sharps injury protection and needleless systems.

Identify and ensure the use of work practice controls. These are practices that reduce the possibility of exposure by changing the way a task is performed.

Provide personal protective equipment (PPE), such as gloves, gowns, eye protection, and masks and the necessary fit testing if using N95 respirators.

Make available hepatitis B vaccinations to all workers with occupational exposure.

Make available post-exposure evaluation and follow-up to any occupationally exposed worker who experiences an exposure incident.

Use labels and signs to communicate hazards.

Provide information and training to workers

Maintain worker medical and training records including sharps injury log

Although the BBP standard is the main OSHA regulation that long term care facilities must follow, the premise of OSHA is one that we as employers must keep in mind at all times; to provide a safe and healthful working environment for our workers, and it carries a very high priority. Whether it is workplace violence, emergency preparedness or BBP we must be aware and always seeking ways to improve and provide the best working place we can for our employees.

COVID -19 placed a huge burden on the post-acute arena to not only keep our residents and clients safe and infection free but also our employees. Many of us lost employees to this pandemic infection. Those employees may have contracted the infection in the community or possibly at work. With that in mind we have reporting responsibilities not only to the Centers for Medicare & Medicaid Services (CMS), CDC, NSHN but also to OSHA.

OSHA was and is very much involved as evidenced by the three Interim Enforcement Response plan memorandums issued April 13, 2020, May 19, 2020 and March 3, 2021 involving annual fit testing of respiratory protection; six enforcement discretion memorandums dating from March 14, 2020 to Oct. 2, 2020 regarding respiratory protection; and three other memorandums addressing recording and reporting occupational injuries and illnesses and various standards that require annual or recurring audits, reviews, training or assessments.

OSHA has been surveying post-acute care facilities through the pandemic:
- 310 OSHA surveys have taken place in 23 states as of Jan. 14, 2021
- 912 tags have been issued resulting in more than $4 million in fines
- New York had 64 surveys with 172 tags and New Jersey had 101 surveys with 324 tags

The tags issued were similar among the 310 surveys (some facilities had multiple surveys done); they included PPE and reporting.
 1910.134(e) Medical evaluation: specifies the minimum requirements for medical evaluation that employers must implement to determine the employee's ability to use a respirator
 1910.134(e)(1) General: employer shall provide a medical evaluation to determine the employee's ability to use a respirator, before the employee is fit tested or required to use the respirator in the workplace.
 1910.134(f)(1) Fit Testing: Fit testing is required prior to initial use, whenever a different respirator facepiece is used, and at least annually thereafter.
 1910.134(g)(1)(i)(A) The employer shall not permit respirators with tight-fitting facepieces to be worn by employees who have facial hair that comes between the sealing surface of the facepiece and the face or that interferes with valve function;
 1904.29(a) Basic requirement. OSHA 300, 300-A, and 301 forms, or equivalent forms, for recordable injuries and illnesses must be used. The OSHA 300 form is called the Log of Work-Related Injuries and Illnesses, the 300-A is the Summary of Work-Related Injuries and Illnesses, and the OSHA 301 form is called the Injury and Illness Incident Report. (https://www.osha.gov/recordkeeping/forms)
 1904.39(a)(1) Within eight (8) hours after the death of any employee as a result of a work-related incident, you must report the fatality to the Occupational Safety and Health Administration (OSHA), U.S. Department of Labor.
 1904.39(a)(2) Within twenty-four (24) hours after the in-patient hospitalization of one or more employees or an employee's amputation or an employee's loss of an eye, as a result of a work-related incident, you must report the in-patient hospitalization, amputation, or loss of an eye to OSHA.
 1904.39(a)(3) You must report the fatality, inpatient hospitalization, amputation, or loss of an eye

In reviewing complaints to OSHA regarding essential industries (healthcare, retail trade, grocery stores, construction, general warehousing, restaurants/eating establishments and auto repair) healthcare had 45 percent of the complaints issued.

The take-away from all this data are some questions that we need to ask ourselves regarding our facility and OSHA responsibilities:
- Do we have a complete BBP plan that is reviewed annually?
- Are we providing the training on the BBP plan and do we make it available to our employees?
- Are providing the appropriate PPE and providing fit testing when employees use N95 respirators?
- Are we gathering input from our employees and using that data to edit and improve our plan?
- Are we documenting and retaining that documentation for the time period indicated?
- Are we using the OSHA forms 300, 300A, and 301 and posting 300A from Feb. 1 to April 30 each year?
- How satisfied are our employees with the efforts we are expending to keep them safe?

Are we ready for a visit from OSHA? Can we afford to be unprepared for the sake of our residents/clients and staff? If you haven’t given OSHA much attention in the past, it might be time to sit down and do a thorough review of the facility BBP plan, supplies/equipment and reporting process.

Cindy Fronning, RN, GERO-BC, IP-BC, AS-BC, RAC-CT, CDONA, FACDONA is a master trainer and director of education for the National Association of Directors of Nursing Administration in Long-Term Care (NADONA).

1. https://www.osha.gov/aboutosha
2. https://www.osha.gov/bloodborne-pathogens/hazards


Standard Precautions Versus Universal Precautions to Control BBPs