Health inspection·November 7, 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 review of policy and procedures, the facility failed to adhere to infection control practice standards during incontinence care for 2 out of 3 residents reviewed for incontinence care (Residents #5 and #6). Residents Affected - Few Findings include: 1. Review of the admission record documented that Resident #5 was admitted to the facility on [DATE] with the following diagnoses displaced intertrochanteric facture of the left femur, subsequent encounter for closed fracture with routine healing, chronic obstructive pulmonary disease, with (acute) exacerbation, atherosclerotic heart disease of native coronary artery heart disease) without angina pectoris (chest pain), primary generalized osteoarthritis and essential primary hypertension. During an observation on 11/7/2024 at 10:40 AM, Resident #5 was lying in bed with the television on. There were incontinence briefs on Resident #5's dresser. During an interview on 11/7/2024 at 10:40 AM, Resident #5 stated, I am incontinent and can't get up by myself. During an observation of incontinence care for Resident #5 on 11/7/2024 at 12:15 PM, Staff B, Certified Nursing Assistant (CNA), was gathering all supplies. Staff B donned gloves without performing hand hygiene, removed the soiled incontinence brief, performed incontinence care and applied barrier cream to Resident #5's buttocks without changing soiled gloves and placed a clean brief on Resident #5. Staff B placed a clean under pad under Resident #5 without changing soiled gloves. During an interview on 11/7/2024 at 12:25 PM, Staff B, CNA, stated, I should have washed my hands and put on clean gloves after I applied [Resident #5's name] barrier cream, before I changed her brief and the bed pad. 2. Review of the admission Record documented that Resident #6 was admitted to the facility on [DATE] with the following diagnoses, Acute embolism and thrombosis of deep veins of the left lower extremity ( a blood clot in the left lower leg), other pulmonary embolism (a blood clot in the lung) without acute cor pulmonale (enlarged right side of the heart), type 2 diabetes mellitus with unspecified complications, paroxysmal atrial fibrillation(an irregular heart beat),and essential primary hypertension. During an observation of incontinence care for Resident #6 on 11/7/2024 at 1:30 PM, Staff A, CNA, donned gloves and removed Resident #6's soiled brief, performed incontinence care, and without Page 1 of 2 105652 105652 11/07/2024 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few changing gloves, opened the plastic bag containing linens, placed a clean under pad and clean brief on Resident #6 without changing soiled gloves. During an interview on 11/7/2024 at 1:40 PM, Staff A, CNA, stated, I should have changed my gloves and washed my hands after I finished peri-care, before I got into the clean linens. I should have done that to maintain infection control. Review of the policy and procedure titled Nursing-Perineal Care read, Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Procedure: 1. Wash your hands thoroughly before beginning the procedure . 19. Remove disposable gloves. Discard into designated container. Wash hands . 26. Wash hands. Review of the policy and procedure titled Handwashing/Hand Hygiene read, Policy Statement: The facility considers hand hygiene to be the primary means to prevent the spread of infections. Policy interpretation and Implementation: 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 5. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . b. before and after direct contact with residents . h. Before moving from contaminated body site to clean body site during resident care during resident care; i. after contact with a resident's intact skin. 105652 Page 2 of 2