Health inspection·October 24, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, policy review, and interview, the facility failed to ensure infection control standards were followed regarding sanitary pericare technique. This affected one resident (#14) of three residents reviewed for infection control. Residents Affected - Some Findings include: Observation on 10/23/24 at 1:45 P.M. of pericare for Resident #14 took place with State Tested Nurse Aides (STNA) #76 and #77. After both STNA's washed their hands and gloved, STNA #76 revealed the facility used moist washcloths to cleanse the resident. STNA #76 wiped the right and left groin from front to back, changing areas on the cloth and then dried with a towel. STNA #76 swiped down the front of the of the labia from front to back with a moist wash rag without spreading the residents' legs or separating the labia. She then dried from front to back down the front of the labia without separating the labia. STNA #77 rolled Resident #14 to her right side. The resident had a bowel movement. STNA #76 cleaned the bowel movement with wet washcloths from the rectal area toward the vagina/urethral opening. After cleaning the bowel movement, STNA #76 dried the area wiping from the rectal area toward the vagina. STNA #76 placed a clean brief across the resident's buttocks, the resident was rolled onto her back. The STNA's started to pull the brief up between her legs when they were stopped by the surveyor. The surveyor questioned whether the resident was clean from pushing the bowel movement toward the vagina and not separating the labia to clean. STNA #77 took clean washcloths and cleansed from front to back while attempting to separate the residents' legs. The wash cloths were fully soiled with bowel movement and took six wipes for the washcloths to present clean. She then dried pulled up the brief and fastened. State Tested Nurse Aides (STNA) #76 and #77 pulled the sheet and comforter up to the resident's torso before removing their gloves. They were wearing the same gloves used to clean up the bowel movement. STNA #77 used the bed control to adjust the bed for the resident after removing her gloves and before washing her hands. The aides left the room with the bag of soiled linen to place with the soiled linen before washing their hands. Review of the Perineal Care policy (revised 08/08/14) included for women to separate the labia and clean downward from the front to back with one stroke repeat with the clean area of the cloth until the area is clean. Rinse the area with a clean washcloth again using the same front to back strokes and pat the area dry. Remove gloves and wash hands. Interview on 10/23/24 at 1:55 P.M. with STNA #76 verified she cleansed the resident's anal area by pushing the bowel movement toward instead of away from the vagina. Further verified the resident's legs were not separated to separate the labia. STNA #77 verified after the resident was turned back on her back and her labia and perineum re-cleansed, the washcloths were soiled with bowel movement that would have been left on the resident when the clean brief was applied. Interview on 10/23/24 at 2:01 P.M. with the Director of Nursing verified the policy included to wipe front to back and remove gloves and wash hands. The DON verified the soiled gloves are to be removed before touching the bedding. This deficiency represents non-compliance investigated under Complaint Number OH00158350. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365417 If continuation sheet Page 2 of 2