Health inspection·January 17, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the facility ' s policy and procedure titled General Policies for IV (IV- is used to give medications and fluids directly to the vein) therapy, was implemented to infection control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) to prevent infection for one of two sampled residents (Resident 2). Residents Affected - Few This deficient practice placed the residents at risk for potential infection or cross contamination of infections (the physical movement or transfer of harmful bacteria from one person, object, or place to another. Findings: A review of an admission Records indicated resident 2 was admitted to the facility on [DATE] with diagnoses including cellulitis (bacterial skin infection) of left lower limb (leg) and Gastro-esophageal reflux disease (GERD-stomach acid flows into the food pipe and irritates the lining). A review of the Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 11/7/23, indicated Resident 2 was cognitively (a mental process of acquiring knowledge and understanding) intact. The MDS indicated Resident 2 was totally dependent on staff for toilet use, eating, bed mobility and dressing. A review of Resident 2 ' s Order Summary Report for January 2024, indicated Resident 2 has the following orders: 1. Ertapenem (medication to treat infection) 1 GM (gram- a unit of measurement of weight and mass) intravenously (medication delivered into a vein through a catheter) every 24 hours for UTI (Urinary Tract Infection – an infection in any part of the urinary system [kidney, bladder, or urethra]), 2. Change IV tubing every 24 hours for five days 3. Peripheral site (IV insertion site -a small, short plastic catheter that is placed through the skin into a vein, usually in the hand, elbow, or foot) care every 96 hours for site care. During an observation in Resident 2 ' s room on 1/17/24 at 10:20 a.m., Resident 2 was observed lying in bed with an IV line on resident ' s left hand. The tubing was observed without label of the name of the resident and the date the tubing was first used and when the tubing will be changed. Page 1 of 2 055181 055181 01/17/2024 San Gabriel Conv Center 8035 E Hill Drive Rosemead, CA 91770

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent observation an interview on 1/17/23 at 10:24 a.m. in Resident 2 ' s room, the Treatment Nurse (TXN) verified that Resident 2 ' s IV tubing did not have label with the Resident 2 ' s name, date, time, and when the IV tubing will be changed, and the initial or name of the licensed nurse who first used the tubing. The TXN stated he could not tell when the tubing was last changed. TXN stated the tubing should be changed every 24 hours, or sooner to promote consistency of practice and minimize the risk of infection and consequently reduce the potential harm for the resident. A review of the facility ' s policy and procedure titled, General Policies for IV therapy, dated June 2018, indicated IV tubing will be changed every 72 hours for continue therapy, and every 24 hours for intermittent use. The policy also indicated that IV tubing will be labeled with the date, time, and the name of the nurse hanged the IV tubing. 055181 Page 2 of 2