Health inspection·February 8, 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 to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of 2 residents reviewed for infection control practices in that: Residents Affected - Few RN A failed to perform hand hygiene, wash hands, change gloves and prevent cross contamination while providing wound care for Resident #1. These failures could affect the residents by placing them at risk for the spread of infection. Finding included: Review of Resident #1's Face Sheet dated 02/08/24, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of non-pressure ulcers, urinary tract infection, exposure to covid-19, and candidiasis. Review of Resident #1's Minimum Data Set (MDS) Assessment undated revealed Resident #1 required total assistance with most activities of daily living (ADLs) and was always incontinent of bowel and bladder. Review of Resident #1's care plan dated 08/03/22 revealed he was at risk pressure ulcers and skin breakdown related poor intake, abnormal labs, incontinence, and impaired mobility. Observation of wound care on Resident #1 on 02/08/24 at 11:30 a.m. revealed RN A did not wash hands but donned gloves before the start of care. She prepared a clean field on a paper spreader. RN A communicated and positioned Resident #1. She removed old dressing revealing a thin reddish clear dry wound on the left heel. RN A cleansed the wound with normal saline and patted dry. She did not wash hands, change gloves, or perform hand hygiene before retrieving the clean kerlix gauze bandage roll. As RN A was covering the wound with the kerlix gauze, it fell on the floor. She picked it up and continued to use it to cover the wound. RN A did not change or replace the dressing. In an interview on 02/08/24 at 11:46 a.m. with RN A, she said he had been employed in the facility for one year. She noted she received infection control training in November 2023. RN A stated she should have washed her hands, performed hand hygiene before retrieving the clean kerlix gauze. She said cross contamination was mixing clean with dirty and the resident could get sick if good infection practice was not followed. Page 1 of 2 455965 455965 02/08/2024 Texhoma Christian Care Center Inc 300 Loop 11 Wichita Falls, TX 76306

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with the ADON on 02/08/24 at 4:23 p.m. she acknowledged he was aware of some of the concerns raised about infection control practices. The DON stated she expected the nurses to wash hands and change gloves at appropriate times while providing wound care. Review of the facility's hand washing/hand hygiene policy revised August 2019 reflected, The facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and implementation: 1) All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2) All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors . 3) Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a) When hands are visibly soiled and b) After contact with a resident with infectious diarrhea including, but not limited to infections caused norovirus, salmonella, shigella and C. difficile. 455965 Page 2 of 2