Health inspection·January 5, 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 record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 2 residents (Resident #5) reviewed for infection control, in that: Residents Affected - Few While providing incontinent care for Resident #5 CNA A did not wash or sanitize her hands between change of gloves, before touching the resident's briefs and after cleaning the resident's buttocks' area. These deficient practices could place residents at-risk for infection due to improper care practices. The findings include: Record review of Resident #5's face sheet, dated 01/05/2024, revealed a [AGE] year old female resident with an admission date of 09/19/2023, with diagnoses which included: Encephalopathy (disorder or disease of the brain), History of urinary tract infection (an infection in any part of the urinary system), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Alcohol abuse (unhealthy drinking behavior). Record review of Resident #5's Quarterly MDS, dated [DATE] revealed Resident #5 had a BIMS score of 5, indicating severe cognitive impairment. Resident #5 was coded as always incontinent of bowel and bladder. Record review of Resident #5's Optional State assessment MDS revealed Resident #5 needed extensive assistance with her activities of daily living. Review of Resident #5's care plan, dated 09/19/2023, revealed a problem of FUNCTIONING DEFICIT- I have physical functioning deficit related to: Dx: Encephalopathy/, with an intervention of Toileting assistance of one. Observation on 01/05/2024 at 9:19 a.m. revealed while providing incontinent care for Resident #5, CNA A cleaned Resident #5's buttocks, changed her gloves, then placed a clean brief on the resident. CNA A did not wash or sanitize her hands, between change of gloves, before touching the clean briefs and fastening the briefs to the resident. During an interview with CNA A on 01/05/2024 at 9:25 a.m., CNA A verbally confirmed she did not Page 1 of 2 455549 455549 01/05/2024 Jourdanton Nursing and Rehabilitation 1504 Highway 97e Jourdanton, TX 78026

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wash or sanitize her hands, between change of gloves, before touching the clean brief and fastening the brief to the resident. CNA A confirmed she should have wash or sanitize her hands prior to placing the new brief on Resident #5. She confirmed the staff received infection control training regularly. During an interview with the ADON on 01/05/2024 at 9:46 a.m., the ADON confirmed the CNA should have washed or sanitize her hands, between change of gloves and, prior to placing the clean brief under the resident to prevent risk of cross contamination and prevent infection for the resident. She confirmed the staff received infection control training frequently and their skills were checked yearly. The ADON revealed she was doing spot checks weekly to check the skills of the staff. Review of CNA A's CNA proficiency audit , dated 09/27/2023 revealed CNA A met proficiency for incontinent care. Review of facility's policy, titled Perineal care, dated February 2018, revealed 8.m. Wash hands rinse rectal area [ .], n, dry area [ .], 9. Discard disposable items into designated containers., 10. remove gloves and discard into designated containers, 11. wash and dry your hands thoroughly. Review of Guidelines for Hand Hygiene in Healthcare Settings Published 2002 [PDF - 496 KB]; 29-30.Indications for, and limitations of, glove use. · Hand contamination may occur as a result of small, undetected holes in examination gloves (321,361) · Contamination may occur during glove removal (50) · Wearing gloves does not replace the need for hand hygiene (58) · Failure to remove gloves after caring for a patient may lead to transmission of microorganisms from one patient to another (373). 455549 Page 2 of 2