Health inspection·June 28, 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 staff used appropriate PPE (Personal Protective Equipment) while providing direct care for 1 of 5 residents on transmission-based precautions, Resident #2, to help prevent the possible spread of infection and communicable diseases (Photographic evidence obtained). Residents Affected - Few Findings include: During an observation on 6/28/2024 at 9:28 AM, there was a sign on the door of Resident #2 and Resident #3's room that read, STOP: Contact Precautions: In addition to standard precautions . Everyone MUST: Perform hand hygiene with alcohol-based hand rub (ABHR) or soap and water before entering and exiting, wear gown before entering and remove upon exiting, wear gloves before entering and remove upon exiting. Staff A, Certified Nursing Assistant (CNA) lifted Resident #2's right arm and placed an automatic blood pressure cuff around the upper arm and placed a pulse oximeter device (device that measures the pulse and the oxygen level in the body) on the resident's finger and began measuring the vital signs with the machine. Staff A did not have a gown or gloves. Staff B, CNA, entered the room without wearing a gown or gloves, briefly spoke to Staff A and proceeded to Resident #3's bedside and began making her bed, folded some linen and placed Resident #3's linen on her dresser against the wall at the foot of the bed. Staff B then walked over to where Staff A was standing with Resident #2. Staff B touched the foot board of Resident #2's bed, spoke with Staff A and Resident #2 briefly without wearing gloves or a gown, and then left Resident #2 and Resident #3's room. Staff A finished taking the vital signs, wrote them on a piece of paper on top of the vital signs machine with a pen, and disconnected the blood pressure cuff from Resident #2's arm and pulse oximeter device from Resident #2's finger without wearing a gown or gloves and exited Resident #2 and Resident #3's room. Review of Resident #2's admission record showed the resident was admitted on [DATE] with diagnoses including MRSA (Methicillin-Resistant Staphylococcus Aureus) to right foot, Alzheimer's disease, metabolic encephalopathy, cognitive communication deficit, chronic kidney disease (stage 3), dysphagia, and peripheral vascular disease. Review of Resident #2's physician order dated 6/23/2024 read, Contact precautions: MRSA to right foot, every shift until 07/01/2024 23:59 [11:59 PM]. During an interview on 6/28/2024 at 9:32 AM, Staff A, CNA, stated, I am an agency CNA. I don't know which resident [Resident #2 or Resident #3] is on contact precautions in that room [pointing to Contact Precautions sign on the door]. I took her vital signs including her blood pressure on her arm and I used a pulse oximeter on her finger. I should have worn a gown and gloves when entering the room with a contact precautions sign on the door. Page 1 of 2 106036 106036 06/28/2024 Grove Healthcare and Rehabilitation Center and Reh 124 W Norvell Bryant Hwy Hernando, FL 34442

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 6/28/2024 at 9:37 AM, Staff B, CNA, stated, I'm not sure if both residents [Resident #2 and Resident #3] are on contact precautions. I think it's [Resident #2's name]. The residents' door had a contact precaution sign on it. I should have worn gloves and a gown when entering the room because of the sign on the door. During an interview on 6/28/2024 at 10:38 AM, the Director of Nursing (DON) stated, For rooms with contact precautions signs, the staff should always wear PPE while in the room, not just for direct patient care. Contact precautions include wearing a gown and gloves. Review of the facility policy and procedure titled P&P Transmission Based Precautions last reviewed on 1/18/2024 read, Transmission-Based Precautions . Contact: Direct contact with skin, or indirect contact with contaminated surfaces, and physical transfer of organisms (usually on the hands of healthcare workers) from an infected or colonized person to a susceptible host . Contact Precautions . Guidelines for Contact Precautions . Gloves. 1. In addition to wearing gloves as outlined under Standard Precautions, clean, nonsterile gloves are worn when providing direct care (changing clothing, toileting, bathing, dressing changes, etc.) to residents. 2. Wear gloves whenever touching the resident's intact skin or surfaces and articles near the resident (e.g., medical equipment, bed rails). [NAME] gloves upon entry into the room or cubicle . Gowns. 1. [NAME] gown upon entry into the room or cubicle. Remove gown and observe hand hygiene before leaving the resident care environment. 106036 Page 2 of 2