Health inspection·October 6, 2023

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of policy, observation and interview, the facility did not ensure infection control practices were maintained during a wound treatment for Resident #9. This affected one resident (#9) of three residents reviewed for hospice. The facility census was 47. Residents Affected - Few Findings include: Record review was conducted for Resident #9 who was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, type two diabetes mellitus, moderate protein calorie malnutrition, dysphagia following a stroke and peripheral vascular disease. Resident #9 was admitted to hospice on 04/01/23 for a terminal diagnosis of dysphagia. Review of the Minimum Data Set 3.0 assessment, dated 07/10/23, revealed Resident #9 required extensive assistance by one staff for eating, dressing, toileting and hygiene and extensive assistance of two staff for transfers and bed mobility. Review of the plan of care, revised 08/28/23, revealed Resident #9 had potential for pressure ulcer development due to incontinence, impaired mobility, and protein calorie malnutrition. Interventions included administering medications and treatments as ordered and following facility policies for the prevention and treatment of skin breakdown. Review of a physician order dated 09/25/23 revealed Resident #9 had a wound on her coccyx and the treatment was to apply calmoseptine ointment to the wound and pad and protect the wound in the morning on Tuesday, Thursday and Saturday. Observation made on 10/03/23 at 11:15 A.M. of wound care provided to Resident #9 by the Wound Care Nurse Registered Nurse (RN) #801 revealed infection control practices were not followed. During the observation, Hospice Aide (HA) #804 was in the room and continued to perform a complete bed bath on Resident #9 while wound care was being provided by RN #801. HA #804 took the dirty wash rag used to wash the residents back and buttocks area and set it on top the clean four-by-four gauze pads RN #801 had set out with the wound supplies. RN #801 grabbed the dirty wash rag with her gloved hands to move it and with the same gloves grabbed the gauze pads that touched the dirty wash rag and proceeded to cleanse Resident #9's wound to her coccyx with the gauze pads. Interview was conducted on 10/03/23 at 12:48 P.M. with RN #801 who verified she saw the dirty wash rag touch the four-by-four gauzes, and she should not of used those gauzes to cleanse the wound. Review of the facility policy titled Nursing Skin Policies and Procedures, dated 05/01/16, revealed Page 1 of 2 366264 366264 10/06/2023 Brewster Convalescent Center 264 Mohican Street NE Brewster, OH 44613

F 0686 Level of Harm - Minimal harm or potential for actual harm when changing dressings if the wound required a sterile technique, then a sterile field with all needed supplies would be established and standard universal infection control techniques/precautions would be applied. This deficiency was an incidental finding during the investigation of Complaint Number OH00146906. Residents Affected - Few 366264 Page 2 of 2