Health inspection·October 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 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 1 resident (Resident #1) reviewed for infection control, in that: Residents Affected - Few The facility failed to ensure LVN A changed her gloves when moving from a dirty to clean task and failed to use appropriate hand hygiene between glove changes when she provided incontinent care to Resident #1. This deficient practice could place residents at risk for infection due to improper care practices. The findings included: Record review of Resident #1's face sheet dated 10/15/24 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included cognitive communication deficit, profound intellectual disabilities, and benign prostatic hyperplasia without lower urinary tract symptoms. Record review of Resident #1's most recent quarterly MDS assessment, dated 9/27/24 revealed the resident was severely cognitively impaired for daily decision-making skills and was always incontinent of bowel and utilized an indwelling urinary catheter. Observation on 10/16/24 at 9:25 a.m., during incontinent care revealed LVN A removed Resident #1's soiled brief, removed her gloves, did not wash, or sanitize her hands and put on a new pair of gloves. LVN A then obtained a clean brief and placed it on the resident's bed. LVN A continued with incontinent care and wiped the stool from Resident #1's left upper thigh and between the buttocks and anus. LVN A then removed her gloves, washed her hands and left the bedside to obtain a topical medication. LVN A returned with Resident #1's topical medication, went into the bathroom to wash her hands, and used her wet right hand to turn off the faucet. LVN A then put on a new pair of gloves, returned to the resident's bedside and applied the topical medication to the resident's buttocks. LVN A then removed her gloves, did not wash or sanitize her hands and put on a new pair of gloves. LVN A completed incontinent care to Resident #1, took the soiled brief and placed it in a plastic bag, and then with the same gloves took the clean brief and placed it on the resident. During an interview on 10/16/24 at 9:51 a.m., LVN A stated she realized she had missed sanitizing her hands between gloves changes and revealed it was important to do so because it was infection control issue and could result in the resident getting an infection. LVN A further stated she should not Page 1 of 2 455762 455762 10/18/2024 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few have turned off the water faucet with her bare hand because you don't know who else had touched the faucet. LVN A stated she had not realized she did not change her gloves after removing Resident #1's soiled brief and before touching the clean brief, and that it was also considered an infection control issue resulting in the resident vulnerable to infection. LVN A stated she had been in-service and had competency training on infection control almost every week if not once a month. LVN A stated she had been involved in providing training to staff and had been in-serviced by the ADON and DON. During an interview on 10/16/24 at 10:08 a.m., the DON stated, no hand washing between glove changes, going from a dirty area to a clean area during a task, and using your bare hand to turn off the water faucet after washing your hands were all a potential for spread of infection due to improper infection control practices. Record review of LVN A's clinical competency validation document for Hand Hygiene dated 8/15/24 revealed LVN A had satisfied the requirement for proper hand hygiene. Record review of the facility policy and procedure titled Infection Prevention and Control Program, revision date 6/2020 revealed in part, Purpose .ensure the Facility establishes and maintains an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements . Record review of the facility policy and procedure titled, Perineal Care, revision date 6/2020, revealed in part, .Purpose .to maintain cleanliness of the genital area, to reduce odor, and to prevent infection or skin breakdown .Wash hands .put on gloves .Remove gloves. Wash hands or use alcohol-based hand sanitizer .Note: Do not touch anything with soiled gloves after a procedure . 455762 Page 2 of 2