Health inspection·September 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 follow appropriate hand hygiene practices while administering intravenous (IV) antibiotics for 1 of 5 residents reviewed for medication administration of a total sample of 44 residents, (#260), and the facility failed to follow appropriate hand hygiene practices during meal delivery per infection control standards. Residents Affected - Few Findings: 1. Review of resident #260's medical record revealed he was admitted to the facility on [DATE] for orthopedic aftercare, the presence of a right artificial knee joint, and type 2 diabetes. Review of resident #260's 5-day Minimum Data Set (MDS) assessment with Assessment Reference Date of 8/29/23 revealed he had a Brief Interview for Mental Status score of 14 out of 15 which indicated he was cognitively intact. The MDS assessment showed resident #260 required supervision for bed mobility and transfers. Review of resident #260's physician orders revealed an order dated 8/22/23 for Cefepime 2 grams IV every 8 hours for right knee infection. A second IV antibiotic order was dated 8/29/23 for Vancomycin 1.25 grams IV every 12 hours for knee infection. Review of resident #260's Antibiotic Therapy care plan initiated on 8/22/23 noted he had an active right knee infection and received IV antibiotics through 9/22/23. Interventions directed staff to practice good infection control and use Personal Protective Equipment (PPE) as indicated. On 9/11/23 at 6:04 PM, Licensed Practical Nurse (LPN) B prepared the 6:00 PM medication for resident #260. She pulled a bag of Vancomycin from the last drawer in her cart along with a sealed package of tubing without first performing hand hygiene. While walking toward the resident's room, a piece of paper fell on the floor. LPN B picked the item from the floor and discarded it in trash bin next to her medication cart. She then continued walking to resident #260's room without performing hand hygiene. As she entered the room, she grabbed a pair of gloves. She discarded the empty bag of IV antibiotic hanging from the IV pole and donned her gloves without performing hand hygiene. LPN B proceeded to clean the cap at the end of the IV line with an alcohol wipe, flushed the peripherally inserted central catheter line using normal saline, spiked the antibiotic bag with the new tubing, reset the infusion pump to the correct setting, started the infusion, and told the resident it would take two hours to run. She then removed her gloves, discarded them in a trash can inside resident #260's room and stepped out of his room without performing hand hygiene. When asked why she had not performed hand hygiene, she stated she had washed her hands in the kitchen just before removing the antibiotic bag from the medication cart. After discussing the steps taken from the moment she removed the Page 1 of 3 105839 105839 09/14/2023 Terrace of Kissimmee, The 221 Park Place Blvd Kissimmee, FL 34741

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medication from her cart, she recalled she discarded the empty IV bag located on the IV pole and donned her gloves without washing her hands. She stated since she had performed hand hygiene in the kitchen, she did not think it was necessary to do it again. She indicated the purpose of performing hand hygiene was to avoid cross contamination and said, my bad. She indicated hand washing helped prevent bacteria from traveling through the IV and worsening an infection. She acknowledged she did not perform hand hygiene before or after the medication was administered to resident #260 as she should. Review of resident #260's Medications Administration History revealed LPN B administered Vancomycin at least 7 times to this resident since 8/29/23. On 9/13/23 at 11:05 AM, the Nurse Educator explained she assigned Healthcare Academy classes to all staff but classes or in-services regarding infection control were provided by Infection Preventionist. She noted nurses were expected to wash their hands prior to entering residents' rooms and both hand sanitizer and soap and water were acceptable. She explained when administering IV antibiotics, the nurses were expected to wash their hands before and after administration. On 9/13/23 at 12:13 PM, the Infection Preventionist stated her responsibilities included in-servicing staff regarding infection control policies and procedures. She stated she performed weekly hand hygiene and PPE audits. She explained during medication administration, the nurses were expected to perform hand hygiene when going from one resident to another, during administration for the same resident if changing route of administration or needed to go out of the room for any reason. She stated hand hygiene must be performed prior to donning and after doffing gloves. The Infection Preventionist explained LPN B told her she washed her hands too early. She shared resident #260 was receiving IV antibiotic for a knee infection and was already immunocompromised. She indicated not performing proper hand hygiene could expose him to bacteria worsening his infection and extending his IV therapy. On 9/13/23 at 4:56 PM, the Director of Nursing (DON) stated nurses were expected to follow infection control procedures when administering medications. She indicated competency was checked with LPNs to ensure proficiency during IV medication administration. Review of the policy and procedure titled Administering Medications revised in December 2020 read, Staff follows established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. 2. On 9/11/23 at 12:43 PM, the lunch meal cart arrived on the 300-hall of the North wing and 2 staff members delivered trays to the resident rooms. The two staff utilized alcohol-based gel (ABG) to sanitize their hands before picking up a resident tray and again after they came out of a resident room. A few minutes later at approximately 12:50 PM Certified Nursing Assistant (CNA) A approached the cart and started to assist the other two staff to deliver trays. Without washing her hands or using the ABG from the dispensers located every few rooms to sanitize her hands, CNA A took a tray off the cart and proceeded to a room to deliver the tray. A few minutes later CNA A came out of the resident's room and headed back to the cart without washing her hands or sanitizing. CNA A got drinks and took a new lunch tray without cleaning her hands and headed to another room. CNA A was observed repeatedly going in and out of 4 resident rooms delivering and uncovering resident's food without washing or sanitizing her hands. On 9/11/23 at approximately 1:02 PM, CNA A stated she was supposed to wash her hands or sanitize them using the ABG before and after each tray she delivered. She did not explain why she did not clean her hands while delivering the trays and going in and out of resident rooms and said, it just 105839 Page 2 of 3 105839 09/14/2023 Terrace of Kissimmee, The 221 Park Place Blvd Kissimmee, FL 34741

F 0880 slipped her mind. Level of Harm - Minimal harm or potential for actual harm On 9/13/23 at 12:14 PM, the Infection Preventionist stated she did weekly audits in the facility for hand-washing and reported to the Quality Assurance committee as well as attended all clinical meetings at the facility. She stated if she heard of someone who did not clean their hands she would do a hands-on education that included when to use ABG to sanitize, when to wash hands, and give a return demonstration of the process. The Infection Preventionist stated she tried to encourage the staff to make it a habit to use the alcohol gel when going both in and out of each room, even if they had washed their hands. She said her expectation was for staff to sanitize their hands, then pick up the meal tray, deliver it to the room and then sanitize their hands using the ABG or wash their hands before coming out of each room and taking the next tray. She stated CNA A was a new CNA and explained she may not have developed the habit to clean her hands every time. Residents Affected - Few Review of the Handwashing/Hand Hygiene policy revised August 2015, revealed the facility considered hand hygiene the primary mean to prevent the spread of infection. The procedure included staff to use an alcohol-based hand rub or wash with soap and water both before preparing or handling medications, before handling any invasive device such as an intravenous catheter line, after handling equipment in a resident's room, after removing gloves, and before and after handling food or assisting a resident with meals. The policy described the use of gloves not a replacement for hand hygiene and using gloves along with routine hand hygiene as the best practice for preventing healthcare associated infections. The undated Infection Prevention and Control Program described the primary mission to establish and maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. This policy included written standards and procedures including hand hygiene to be followed by staff involved in direct resident contact. Review of the Facility Assessment reviewed by the Quality Assurance & Performance Improvement Committee on 11/16/22 revealed staff received education and were competent in infection control processes. 105839 Page 3 of 3