Health inspection·May 8, 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 medical record review, staff interview, observation, and facility policy review, this facility failed to ensure enhanced barrier protection including gloves were in place during wound care. This affected one (Resident #126) of the three residents reviewed for wound care. The facility census was 91. Residents Affected - Few Findings include: Review of the medical record for Resident #126 revealed and admission date of 10/22/24. Diagnoses included type two diabetes mellitus, foot ulcers, and peripheral vascular disease. Review of Resident #126's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating a moderately impaired cognition for daily decision making abilities. Resident #126 was noted to have one venous and arterial ulcer, and a diabetic foot ulcer. Review of the care plan dated 03/20/24 and revised 04/13/24 revealed Resident #126 had impaired skin integrity, or was at risk for altered skin integrity due to right lateral foot ulcer, left skin skin tear, right knee skin tear, right top foot skin tear, left lateral foot arterial ulcer, left groin surgical, and left forearm skin tear. Interventions include to complete daily skin checks, and complete treatments as ordered. Review of treatment orders for Resident #126 revealed the following: -Cleanse with house wound cleanser, apply Calcium Alginate to areas on right lateral foot, cover with gauze and Kerlix. -Cleanse wound to dorsal right foot with normal saline solution, pat dry and apply Betadine to wound bed, and leave open to air daily. -Cleanse wound to left lateral foot with normal saline solution, pat dry apply Betadine to wound bed and leave open to air daily. -Cleanse wound to left lateral heel with normal saline solution or wound cleanser, apply Medihoney to wound bed and cover with gauze and wrap with Kerlix every day shift. -Cleanse wound to left shin with normal saline solution, pat dry apply skin prep to wound bed and Page 1 of 2 365313 365313 05/08/2024 Bridgeport Health Care Center 2125 Royce Street Portsmouth, OH 45662

F 0880 leave open to air daily. Level of Harm - Minimal harm or potential for actual harm -Cleanse wound to right foot 5th digit with normal saline solution, apply skin prep to wound bed and leave open to air daily. Residents Affected - Few -Cleanse wound to right knee with normal saline solution, pat dry apply skin prep to wound bed and leave open to air daily. -Cleanse wound to top of left foot with normal saline solution, pat dry apply Betadine to wound bed and leave open to air daily. Observation on 05/07/24 at 11:22 A.M. revealed during general observations Resident #126's room door was open and Licensed Practical Nurse (LPN) #135 could be seen completing a dressing change for Resident #126. Continued observation revealed LPN #135 did not have a gown or gloves on and was observed using a split gauze to spray house wound cleanser on and then cleanse the resident wound which appeared to be on the right lower leg. LPN #135 continued to opened a bandage package, applied ointment to the bandage and then placed the bandage directly on the wound followed by opening another bandage package, applied ointment to the bandage and placed it on the residents other wound. LPN #135 was then observed leaving the residents room without washing her hands. Interview on 05/07/2024 at 11:24 A.M. with LPN #135 revealed when starting the dressing change, she had gloves on but removed them due to getting Betadine on the gloves. LPN #135 confirmed she did not have gloves or a gown on during dressing change for Resident #126. LPN # 135 also confirmed she did not wash her hands prior to exiting the resident room. Interview on 05/07/2024 at 11:38 A.M. with the Administrator confirmed residents with chronic wounds, including Resident #126 should be in enhanced barrier precaution isolation which included the use of gloves and gown when completing care such as wound care. Review of the facility policy titled Standard Precautions, dated 06/24/2021 revealed under section II. When to perform Hand Hygiene, B. Before and after direct contact with a resident's intact skin. C. After contact with blood, body fluids or exertions, mucous membranes, non-intact skin or wound dressing. This deficiency was an incidental finding during investigation for Master Complaint Number OH00153465. 365313 Page 2 of 2