Health inspection·March 15, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 of 3 staff (LVN-B, CNA-D, CNA-C) reviewed for infection control procedures. Residents Affected - Some The facility failed to ensure the LVN-B perform proper hand hygiene before and after providing resident care. The facility failed to ensure the CNA-D perform proper hand hygiene before and after removal of gloves. The facility failed to ensure the CNA-C performed incontinent care in accordance with facility policy. These failures could place residents at risk for the transmission of communicable diseases. Findings included: During an observation and interview on 03/14/2024 at 9:33 a.m., LVN B was observed performing medication pass. LVN B went into resident's room to obtain blood pressure using wrist cuff and did not perform hand hygiene before or after leaving room. LVN B brought in a different wrist blood pressure cuff into room to attempt to obtain another blood pressure without performing hand hygiene before or after leaving room. She opened medication cart and dispensed scheduled medications into cup. LVN B brought medication and water into resident's room and watched as he swallowed medications then she left room without performing hand hygiene. She went to medication cart to open and count narcotic sheets and did not perform hand hygiene. LVN B stated that she has had training on infection control. She stated hand hygiene should have been performed upon entering and leaving resident's room. She stated she had been busy that morning and nerves also contributed to her not performing hand hygiene. She stated not performing could cause spread of infection from one resident to another. During an observation and interview on 03/14/2024 at 10:04 a.m., CNA D performed urine incontinent care for resident. She rolled resident to the right side and cleansed buttocks with wipes. She reused wipes after folding in half. She then applied cream to resident's buttocks with right gloved hand. She removed right glove on right hand and threw into trash receptacle. She then put on another glove to right hand without performing hand hygiene. She placed a new brief under resident and instructed for her to roll onto back. CNA D then wiped front or resident toward the back reusing wipe after folding in half. CNA D secured brief onto resident and removed her gloves throwing into trash receptacle. CNA D did not perform hand hygiene and started opening drawer to get pants out. CNA D stated Page 1 of 3 455957 455957 03/15/2024 Santa Fe Health & Rehabilitation Center 1205 Santa Fe Dr 1205 Santa Fe Dr, TX 76086

F 0880 Level of Harm - Minimal harm or potential for actual harm that she was unsure if hand hygiene needed to be performed when changing gloves. CNA D stated that she should have cleansed front of resident before cleansing back when performing incontinent care. She wasn't sure why she cleansed back prior to cleansing front but felt that being nervous may have made her perform wrong. She did not know what facility policy stated on hand hygiene or incontinent care. She stated performing incontinent care incorrectly could cause resident to have infection. Residents Affected - Some During an observation on 03/14/2024 at 10:13 a.m., CNA C performed bowel incontinent care. CNA C used disposable wipe to collect stool and then folded wipe in half and reused again to wipe skin. She disposed of soiled wipes into trach receptacle and did not remove gloves. She opened dresser drawer to get clean brief and placed under the resident. She removed gloves after and washed her hands with soap and water. During an interview on 03/14/2024 at 10:25 a.m., CNA C stated she should have replaced gloves and performed hand hygiene before opening drawer to obtain clean brief. She stated it was not appropriate to fold disposable wipes in half and continue to clean skin but should have gotten new wipe each time. She felt that being rushed to perform incontinent care led to failure since wound care nurse was performing care at the time incontinence occurred. CNA C stated she had been trained on infection control and that not performing incontinent care correctly could lead to resident having infections. During an interview on 03/14/2024 at 3:23 p.m., the DON stated his expectation of staff would be that hand hygiene be performed when entering and exiting a resident's room. He stated it would not be appropriate to reuse disposable wipes after folding and he expected new wipe to be used every time. The DON stated he expected staff to perform hand hygiene before and after removing gloves and failing to perform hand hygiene could cause infections to spread and residents to become sick. The DON stated he did not know why staff failed to perform hand hygiene appropriately and LVN B was an infection preventionist at the facility. He stated that both him and the ADONs were responsible to monitor that staff were knowledgeable in infection control and performed resident care appropriately to help prevent risk of infections from occurring. Record review on 03/14/2024 at 3:20 p.m. revealed LVN B, CNA C, and CNA D had infection control training upon hire and then annually. Review of facility policy titled Hand Hygiene dated 02/11/2022 revealed: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR) .Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table .The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Hand hygiene table revealed: Either soap and water or alcohol-based hand rub should be used between resident contacts; after handling contaminated objects; before applying and after removing personal protective equipment including gloves; before preparing or handling medications; before performing resident care procedures; after handling items potentially contaminated with blood, body fluids, secretions or excretions. Review of facility policy titled Incontinence Care dated 02/14/2020 revealed: If feces present, remove with toilet paper or disposable wipe by wiping from front of perineum toward rectum. Discard soiled materials and gloves. Wash hands. Put on non-sterile, latex-free gloves. Position on back with knees flexed and feet flat on bed (care may also be provided with patient sitting on commode or shower chair or in a standing position). Cleanse peri-area and buttocks with cleansing agent wiping from 455957 Page 2 of 3 455957 03/15/2024 Santa Fe Health & Rehabilitation Center 1205 Santa Fe Dr 1205 Santa Fe Dr, TX 76086

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some front of perineum toward rectum. Turn patient side to side to cleanse entire affected area, as needed. Rinse with water, if needed or per incontinent product manufacturer's instructions. Dry peri-area and buttocks from front to back. Apply skin protectant products, if needed and, or as ordered, per manufacturer's instructions. Remove linen/ underpad and discard. Remove and discard gloves. Wash hands. Apply clean linen/underpad, brief or other incontinent products, as needed. Reposition for comfort with call light in reach and provide additional care as needed as requested by patient. Return equipment to designated area and clean/dispose as indicated. 455957 Page 3 of 3