Health inspection·July 14, 2023

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 outside consultant healthcare practitioners followed PPE requirements for transmission-based precautions during a COVID-19 (a respiratory illness) outbreak for one of three sampled residents. Residents Affected - Few This failure placed Resident 1 at risk of respiratory infection and urinary tract infection (UTI, infection that can affect the bladder, kidneys and connecting components) potentially leading to morbidity and mortality. Findings: A review of Resident 1's admission record, indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of dementia and neuromuscular dysfunction of the bladder (condition which bladder does not drain naturally). A review of Resident 1's physician's orders, indicated Resident 1 had an order, dated 2/6/23, for a foley catheter (tubular device inserted in the urethra to drain urine) and an order for enhanced barrier protection, dated 1/2/23, related to the foley catheter. A review of facility's list of COVID-19 positive residents, dated 7/14/23, indicated the facility had 10 residents that were positive for COVID-19 and the residents were quarantined in a redzone. During an observation and interview on 7/14/23, at 11:00 a.m., with Licensed Vocational Nurse 1 (LVN 1), ultrasound consultant (UC) was observed in Resident 1's room sitting on a chair by Resident 1's bed typing on a computer. UC was not wearing a gown while she was in the room. Resident 1 was in her bed sitting up with no facemask on and had a foley catheter. LVN 1 observed UC in Resident 1's room with a standard facemask and no gown. LVN 1 stated UC was required to wear an N95 respirator because of the COVID outbreak. LVN 1 stated Resident 1 was on enhanced barrier precautions to prevent contamination of her foley catheter and UC needed to wear a protective gown for patient contact activities. During an observation on 7/14/23, at 11:05 a.m., a sign outside of Resident 1's door indicated Resident 1's room was on enhanced barrier protection. The sign indicated staff must wear a protective gown for high contact resident care activities. During an interview on 7/14/23, at 11:15 a.m., with UC, UC stated she was in Resident 1's room and performed a kidney ultrasound (diagnostic procedure to visualize the kidneys using a device placed on the back against the skin). UC stated Resident 1 was on an enhanced barrier protection precaution Page 1 of 2 056392 056392 07/14/2023 Pleasanton Nursing and Rehabilitation Center 300 Neal Street Pleasanton, CA 94566

F 0880 Level of Harm - Minimal harm or potential for actual harm and for her procedure, a protective gown needed to be worn. UC stated she did not wear a protective gown when she was in Resident 1's room during the procedure. UC stated she did not know why Resident 1 was on enhanced barrier protection. UC stated she was expected to wear a standard mask while in the facility. UC stated she was not given instructions to wear an N95 respirator when she entered the facility because there were no signs or front desk staff to provide instructions. Residents Affected - Few During an interview and record review on 7/14/23, at 12:40 p.m., with Infection Preventionist (IP), the facility's policy and procedure (P&P), titled Enhanced Barrier Protection, dated 7/22/22, was reviewed. The P&P indicated residents with a foley catheter need to be on enhanced barrier precautions as an infection prevention intervention for residents with a foley catheter. The P&P further indicated residents with a foley catheter were at high risk for developing infections. The P&P indicated gowns were required for any care activity where close contact with the resident is expected to occur. During an interview and record review on 7/14/23, at 10:20 a.m. with IP, the facility's P&P titled Mitigation Plan for Testing, Quarantine, Isolation and Vaccination of Health Care Personnel and Residents, dated 4/3/23, was reviewed. IP stated the P&P was used when there was a COVID outbreak. The P&P indicated staff were expected to wear N95 respirators in resident care areas with potential COVID exposure when the facility had a COVID outbreak. IP stated staff including outside consultants were expected to follow the same P&P. 056392 Page 2 of 2