Health inspection·May 23, 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 observation, interview, and review of facility policy, the facility failed to ensure Enhanced Barrier Precaution (EBP) guidelines were followed for all residents that required EBP. This affected four (Residents #5, #27, #36, #255) of five reviewed for EBP. The facility census was 49. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #36 revealed an admission date of 04/01/24. Diagnoses included sepsis, urinary tract infection, atrial fibrillation, Parkinson's disease, chronic diastolic (congestive) heart failure, and use of indwelling urinary catheter. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 had intact cognition. Resident #36 required use of a urinary catheter. Observation of Resident #36's room on 05/20/24 at 9:20 A.M. revealed no signage for EBP. The room had no gowns or gloves specified for EBP. Interview on 05/20/24 at 9:40 A.M. with Resident #36 revealed he has never been in EBP. Interview with the Infection Control Preventionist (ICP) #317 on 05/20/24 at 11:00 A.M. revealed the facility had not put EBP in place. 2. Review of the medical record for Resident #255 revealed an admission date of 05/12/24 Diagnoses included chronic kidney disease with heart failure, cirrhosis of liver, portal hypertension, diabetes mellitus with diabetic neuropathy, and the resident had a dialysis port and required dialysis three times weekly. Review of the admission MDS assessment dated [DATE] revealed Resident #255 was cognitively intact and required assistance with care. Review of the physician orders for 05/24 revealed no orders for EBP until 05/20/24. Observation of Resident #255 on 05/20/24 at 9:00 A.M. revealed no signage was posted to inform staff of EBP near the resident's room. Interview with the Infection Control Preventionist (ICP) #317 on 05/20/24 at 11:00 A.M. revealed the facility had not put EBP in place. Page 1 of 3 366483 366483 05/23/2024 Harrison Trail Health Campus 10460 Progress Way Harrison, OH 45030

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. Record review of Resident #5 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #5 included encephalopathy, respiratory failure, cerebral palsy, quadriplegia due to cerebral palsy, depression, myalgia, dysphagia, congenital dilatation of esophagus, and hip contracture. Review of the MDS assessment dated [DATE] revealed the resident had intact cognition and required extensive assistance for Activities of Daily Living (ADLs), including mobility dressing and transfers. Record review of Resident #5 revealed the resident had an abdominal tube with a physician order to flush the tubing with 30 milliliters (ml) of water twice a day, cleanse tube site with water and split sponge twice a day and check for residual every shift. Review of physician orders dated 05/20/24 at 1:52 P.M. revealed staff to use EBP, wearing gowns and gloves at minimum, during high contact care activities. Observation on 05/20/24 at 8:45 A.M. revealed Resident #5 was observed to have no signage or other notification of EBP. Interview on 05/20/24 at 8:45 A.M. Licensed Practical Nurse (LPN) #416 verified Resident #5 had no order for EBP until 05/20/24 and there was no notification of EBP in the resident room. LPN #416 verified Resident #5 had an abdominal tube and should have had EBP in place. Interview on 05/21/24 at 3:35 P.M. LPN #400 verified Resident #5 did not have an order for EBP and there had been no signage and notification of EBP until 05/20/24. LPN #400 verified Resident #5 had an abdominal tube and should have had EBP in place. Interview on 05/22/24 at 2:57 P.M., State Tested Nurse Aide (STNA) #300 verified Resident #5 had no EBP signage or notification in the STNA plan of care until the afternoon of 05/20/24. STNA #300 verified staff are required to wear gowns and gloves when providing direct contact care to residents with abdominal tubes. 4. Record review for Resident #27 revealed an admission date of 12/27/23. Diagnoses included sepsis, cystitis without hematuria, displacement of nephrostomy catheter, and peritoneal abscess. The resident had a nephrostomy. Review of the most recent quarterly MDS assessment dated [DATE] revealed the Resident #27 had intact cognition and was independent for all care. Review of the treatment record for Resident #27 revealed Normal Saline Flush (sodium chloride 0.9 %) syringe amount 5 ml, flush left nephrostomy with 5 ml of normal saline two times daily. Review of the monthly physician orders for 05/24 revealed no orders for EBP until 05/20/24 after it was brought to the facility's staff attention. Review of treatment record dated 05/20/24 for Resident #27 revealed staff to use EBP, wearing a gown and gloves at minimum during high-contact care activities twice a day. Observation on 05/20/24 at 9:14 A.M. of Resident #27's room revealed no EBP signage. 366483 Page 2 of 3 366483 05/23/2024 Harrison Trail Health Campus 10460 Progress Way Harrison, OH 45030

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview with LPN #416 on 05/20/24 at approximately 9:30 AM confirmed no EBP signage in Resident #27's room. Review of the facility policy, Enhanced Barrier Precautions, dated 04/02/24 revealed the facility would identify residents with central lines, urinary catheters, feeding tubes, hemodialysis catheters and tracheotomy/ventilator status regardless of Multi drug-resistant Organisms (MDRO) colonization status. High contact resident care activities requiring gown and glove use included but were not limited to tracheotomy/ventilator care. Residents identified with MDRO, wound, and or indwelling medical devices would have an EBP sign noting the Personal Protective Equipment (PPE) needed and the high contact care activities. 366483 Page 3 of 3