Health inspection·May 3, 2023

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 provide wound care and incontinence care to Resident #68 in a manner to promote infection prevention. This affected one resident (#68) of three residents reviewed for wound care and incontinence care. This had the potential to affect all residents in the facility. The facility census was 87. Residents Affected - Few Findings include: Review of the medical record for Resident #68 revealed an admission date of 12/23/22. Diagnoses included respiratory failure with hypoxia, metabolic encephalopathy, atrial fibrillation, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #68 had moderate cognitive impairment. Resident #68 required extensive two-person physical assistance for bed mobility and toilet use; total dependence of two-persons for transfers; extensive one-person assistance for dressing and personal hygiene; and supervision with set-up help only for eating. Resident #68 was always incontinent of urine and bowel. Review of the care plan dated 04/02/23 revealed Resident #68 was incontinent of bowel and bladder. Interventions included checking and changing her every two hours and ensuring her call light was in reach. The care plan also had a focus that Resident #68 had impaired cognitive skills related to metabolic encephalopathy and that Resident #68 was a victim of domestic violence and being left against the wall causes anxiety. Interventions included explaining care before providing it and orienting and reorienting her if it does not upset her. Observation of incontinence care and wound care on 04/25/23 at 2:00 P.M. with State Tested Nurse Aide (STNA) #523 and STNA #530 for Resident #68 revealed they both entered the room with gloves in their hands from their pockets. No hand washing was performed. They transferred Resident #68 into bed in the lift and immediately began incontinence care. Resident #68 had a large bowel movement (BM) and required a new lift pad and pants. STNA #530 removed her gloves went into Resident #68's drawers and removed a new pair of pants while STNA #523 left the room with dirty gloves on and the dirty lift pad and pants not bagged and took them to the dirty linen room, removed her gloves, put on a new pair, grabbed a new lift pad, and returned to the room with no hand hygiene. Licensed Practical Nurse (LPN) #520 then entered the room with gloves on holding wound care supplies. LPN #520 then set her wound care supplies on Resident #68's bedside table with no barrier or precleaning and began performing wound care for Resident #68's buttocks. LPN #520 then removed her gloves after the new dressing was applied and cleaned up her things and left the room. No hand hygiene was performed. STNAs #523 and #530 then began to redress Resident #68 and lifted her into her recliner chair. STNA #530 then Page 1 of 2 366281 366281 05/03/2023 Windsor House at Champion 200 East Glendola Avenue Champion, OH 44483

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few removed her gloves and washed her hands. STNA #530 confirmed that was the first time she had washed her hands. STNA #523 removed her gloves and grabbed dirty linen in her bare hand and took it unbagged to into the hallway and down to the dirty linen room and disposed of it. STNA #523 confirmed she did not complete any hand hygiene during, before, or after the procedure and carried dirty linen unbagged to the dirty linen closet twice. Interview after the observation with LPN #520 confirmed she entered the room with gloves on and placed her supplies on the bedside table with no barrier or precleaning. LPN #520 also confirmed she did not perform any hand hygiene. Review of the facility policy titled Dressing Change, revised August 2022, revealed hand hygiene must be performed before any equipment is gathered. The nurse must set up a clean field by cleaning a table surface with soap and water, after cleaning disinfect with alcohol wipes or Clorox wipes, place clean pad or paper towels on the surface, and place all needed supplies on the clean field. [NAME] gloves and remove old dressing and place in a bag. Remove the dirty gloves and perform hand hygiene. [NAME] new gloves and apply the new dressing. Remove gloves, clean up supplies, and perform hand hygiene. Review of the facility policy titled Handwashing/Hand Hygiene Policy, revised August 2022, revealed employees must perform hand hygiene before contact with residents, after contact with residents' skin, after contact with blood, bodily fluids, or contaminated surfaces, and after contact with inanimate objects in the immediate vicinity of the residents. Review of the facility policy titled Incontinence Care, reviewed January 2017, revealed if a resident requires additional assistance or asks for an item during incontinence care, remove gloves and wash hands before assisting the resident or put on new gloves before returning to the incontinence area. 366281 Page 2 of 2