Health inspection·September 18, 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 interviews, observations, review of online resources from the Centers for Disease Control (CDC), and policy review, the facility failed to ensure staff followed hand hygiene procedures when providing incontinent care. This affected one (#24) resident of three residents reviewed for incontinent care. The facility census was 106. Residents Affected - Few Findings include Review of the medical record for Resident #24 revealed an admission on [DATE] with diagnoses including but not limited to spinal stenosis, Alzheimer's disease, and dementia. Review of the most recent quarterly Minimum Data Set (MDS) assessment for Resident #24 dated 07/19/24 revealed an impaired cognition. Resident #24 required set up for eating, maximum assistance for bed mobility and was dependent on staff for toileting, toileting hygiene and transfers. Resident #24 was assessed as incontinent of bowel and bladder. Observation of incontinence care for Resident #24 on 09/18/24 at 2:09 P.M., with State Tested Nursing Assistant (STNA) #159 revealed the STNA gathered washcloths, two trash bags, and an incontinent garment. STNA #159 went into the resident's bathroom and returned with the washcloths and placed them on the resident's bed side table without a barrier between the two surfaces. Three of the washcloths were in wads and two were opened and laid to the end of the table. STNA #159 instructed the resident of the task, applied gloves and removed the bed sheets. STNA #159 unfastened the incontinent garment rolling it to the center of the perineum and pushed to down towards the bed, exposing the front of the perineal area. STNA #159 used one corner of the washcloth to wipe down the front center of the labia. STNA #159 then noted fecal material on the end of the washcloth. STNA #159 flipped the washcloth over her hand using a clean area to make multiple passes over the inner thighs on both sides without moving washcloth to separate areas. STNA #159 placed the used washcloth into a plastic bag on chair and using a second opened washcloth to make multiple passes over the same perineal area without using a clean area of the washcloth. STNA #159 then asked the resident to roll to her left side exposing the rectal area. Using the third washcloth, the STNA #159 used an upward movement to remove a large portion of the fecal matter from the area and placing it into the trash bag. STNA #159 using a fourth wash cloth that was wadded up wiped the rectal area in multiple passes using different sections of the washcloth by flipping it over her right hand. Resident #24 moaned when STNA #159 cleansed over the right outer sacral area. STNA #159 stating the area was reddened and would apply barrier cream. STNA #159 used the fifth opened washcloth to wipe the rectal area and buttocks without repositioning the washcloth to a clean unused portion. STNA #159 placed the washcloth into the trash bag. STNA #159 then rolled the incontinent garment up and pulled it from underneath the resident and placed it into the second bag on the chair. STNA #159 then opened the nightstand drawer with her gloved Page 1 of 2 365693 365693 09/18/2024 Western Hills Retirement Village 6210 Cleves Warsaw Pike Cincinnati, OH 45233

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hand and removed a tube of barrier cream. STNA #159 flipped the tube open and squeezed the ointment onto her gloved right index finger. STNA #159 then noted a small amount of smeared brown colored material on the tube and on her glove on her right posterior hand. STNA #159 removed the last washcloth from the trash bag on the chair with her left hand and wiped the material off the tube and her glove placing the washcloth back into the trash bag. STNA #159 applied the ointment to the reddened area using her right gloved hand. STNA #159 then removed her gloves placing them into the trash bag and donning new gloves to apply the clean incontinent garment. The resident was repositioned and cover with bed sheets. Interview with STNA #159 on 09/18/24 at 2:35 P.M. verified she removed the smeared brown material from the tube of barrier cream and her gloved hand. STNA #159 placed the tube of barrier cream back on the bed side table of Resident #24. Further verified she did not remove the gloves before applying the barrier cream to the Resident #24 reddened sacral area. STNA #159 verified she did not complete hand hygiene after removing the soiled glove and should have before donning the new gloves. Interview with the Director of Nursing (DON) on 09/18/24 at 4:40 P.M. verified staff should be removing gloves when dirty/wet incontinent garments are removed. The DON verified hand hygiene should be completed every time gloves were removed. Review of the facility policy titled Hand Hygiene, dated 02/28/2020 stated hand hygiene should be completed after removing gloves and if moving from a contaminated body site to a clean body site. Review of online resources from CDC (https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html) dated 02/27/24 titled Clinical Safety: Hand Hygiene for Healthcare Workers, revealed healthcare personnel should complete hand hygiene immediately before touching a patient, before performing an aseptic task such as placing an indwelling device or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or patients surroundings, after contact with blood, body fluids or contaminated surfaces and immediately after glove removal. This deficiency represents non-compliance investigated under Complaint Number OH00156660. 365693 Page 2 of 2