Health inspection·December 11, 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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one of three sampled residents (Resident 1) when Treatment Nurse 1 (TN 1) did not perform hand hygiene (handwash with soap and water or alcohol-based hand rub) in between glove changes during the wound dressing change. This failure had the potential to result in infection and spread of infection. Residents Affected - Few Findings: A review of Resident 1s admission Record, printed 12/11/24, indicated resident was readmitted to the facility on [DATE] with diagnosis of diabetes mellitus (high blood sugar). A review of Resident 1's Physician Order, with a revision date of 12/5/24, indicated a treatment order for resident's sacral region (the triangular shaped bone at the base of the spine that connects the spine to the pelvis) Stage III pressure ulcer (a full thickness tissue loss but do not reach muscle, tendon, or bone). The treatment order indicated, Wound care: Cleanse with normal saline (NS), gently pat dry, apply Santyl (a topical enzyme [proteins that help with wound healing] medication used to remove damaged or burned skin, aiding in wound care and the growth of healthy skin), cover with Mepilex (a soft and highly conformable antimicrobial foam dressing) until healed one time a day . During a concurrent observation and interview on 12/11/24, at 1:20 p.m., TN 1 prepared for Resident 1's wound dressing change. Resident's old wound dressing has been removed during incontinent care just before the wound care began. TN 1 donned a clean pair of gloves, cleansed the wound site with NS, removed soiled gloves, then donned a new pair to apply Santyl to the wound, without performing hand hygiene. As TN 1 continued with Resident 1's wound care, TN 1 covered the wound site with Mepilex dressing, removed her soiled gloves, then donned a new pair again without performing hand hygiene. Upon interview, TN 1 stated hand hygiene should be performed when moving from wound cleaning (a dirty procedure) to application of a new dressing (a clean procedure) to prevent contamination. During an interview on 12/11/24, at 2 p.m., with the Director of Nursing (DON), DON stated changing gloves without performing hand washing or hand hygiene increases the risk of infection. DON stated staff should change gloves and perform hand hygiene in between clean and dirty procedures to prevent spread of infection. A review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, revised date August 2019, indicated, This facility considers hand hygiene the primary means to prevent the spread of infections .All personnel shall follow the handwashing/hand hygiene procedures to help prevent Page 1 of 2 055292 055292 12/11/2024 Shields Richmond Nursing Center 1919 Cutting Blvd Richmond, CA 94804

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the spread of infection to others personnel, residents, and visitors .Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a. When hands are visibly soiled. B. After contact with resident .Use an alcohol-based hand rub containing at least 62 percent (%) alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .b. Before and after direct contact with residents .d. Before performing any non-surgical invasive procedures .g. before handling clean or soiled dressings, gauze pads .h. Before moving from contaminated body site to a clean body site during resident care .k. After handling used dressings, contaminated equipment .m. After removing gloves .The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections . 055292 Page 2 of 2