Health inspection·June 27, 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, record review and facility policy review the facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE) when caring for a resident on the South unit who had orders for Enhanced Barrier Precautions (EBP). This affected one Resident (Resident #51) of three residents reviewed for infection control, and had the potential to affect an additional 23 residents (#33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #52, #53, #54, #55 and #56) living on the South unit. The facility identified 24 residents in EBP (Residents #4, #10, #11, #14, #20, #27, #30, #31, #33, #41, #47, #48, #50, #51, #52, #54, #58, #75, #81, #86, #87, #88, #97, and #103). The facility census was 106. Residents Affected - Some Findings include: Review of the medical record for Resident #51 revealed an admission date of 02/23/24. Diagnosis included type two diabetes mellitus, anoxic brain damage, urinary tract infection, acute respiratory failure with hypoxia, infection and inflammatory reaction due to indwelling urethral catheter, and a personal history of other infectious and parasitic disease sepsis due to staph Aureus. Review of Resident #51's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition and was dependent on staff for all Activities of Daily Living (ADLs). Review of Resident #51's physician orders dated June 2024 revealed she was in Enhanced Barrier Precautions (EBP) and staff were to use gown and gloves for high-contact resident care including dressing, bathing, showering, transfers, hygiene care, changing linens, changing briefs, assisting with toileting, dressing changes, and care of any device (trach, central line, tube feeding, and catheter) every shift for reducing the chance of spreading infection. Further review of Resident #51's physicians orders revealed she had a foley catheter, tube feedings, and wound care. Observation on 06/27/24 at 11:45 A.M. of Resident #51 revealed she was to be in Enhanced Barrier Precautions related to her heel wound, and lines and tubes such as foley catheter and tube feeding. Observation on 06/27/24 at 11:47 A.M. of wound care for Resident #51 by Registered Nurse (RN) #705 revealed she cleansed the left heal with saline soaked gauze, painted with betadine then applied Adaptic, then applied a clean dry dressing and reapplied the residents heel boots. Hand hygiene was completed appropriately with no concerns identified related to the wound care. While RN #705 performed wound care she was not wearing the proper Personal Protective Equipment (PPE) as required including Page 1 of 2 365033 365033 06/27/2024 Cedarwood Plaza 12504 Cedar Road Cleveland Heights, OH 44106

F 0880 a gown. Level of Harm - Minimal harm or potential for actual harm Interview on 06/27/24 at 12:00 P.M. with RN #705 the facility Wound Care Nurse and Infection Preventionist revealed she confirmed Resident #51 whom she just completed wound care on was in Enhanced Barrier Precautions (EBP) and should have worn a gown to complete the residents wound care and did not. She stated she got caught up in the moment and forgot to put on her gown. She confirmed all appropriate signage was posted. Residents Affected - Some Review of the facility policy titled Enhanced Barrier Precautions, last reviewed 11/30/23 revealed under the procedure section, number two Gowns and gloves are to be used for high-contact resident care activities for residents known to be colonized or infected with a Multi-Drug Resistant Organism (MDRO) as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Under number three it stated examples of high-contact resident care activities requiring gown and glove use for EBP include: dressing, bathing/showering, transferring, providing hygiene, changing lines, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tubes, tracheostomy/ventilator, wound care including any skin opening requiring a dressing. This deficiency was an incidental finding of non-compliance during the investigation of Complaint Number OH00154399. 365033 Page 2 of 2