Health inspection·August 23, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review and facility policy review, the facility failed to ensure staff performed hand hygiene during wound care for 1 (Resident #55)of 1 sampled resident reviewed for pressure ulcer/injury. Residents Affected - Few Findings include: A facility policy titled, Handwashing/Hand Hygiene, revised 10/2023, specified, Indications for Hand Hygiene. 1. Hand hygiene is indicated: f. before moving from work on a soiled body site to a clean body site on the same resident. The policy further specified, 4. Single-use disposable gloves should be used: a. before aseptic procedures. An admission Record revealed the facility admitted Resident #55 on 04/14/2023. According to the admission Record, the resident had a medical history that included a diagnosis of pressure ulcer of the sacral region, stage 4. Resident #55's Order Summary Report, revealed an order dated 08/09/2024, for staff to cleanse Resident #55's coccyx wound with wound cleanser, pat it dry, pack the wound with collagen powder, cover with calcium alginate and a foam dressing every day. During an observation of wound care on 08/21/2024 from 10:11 AM to 10:25 AM, Licensed Vocational Nurse (LVN) #1 provided wound care to Resident #55. At 10:19 AM, LVN #1 removed the resident's soiled dressing and packing. LVN #1 disposed of the dressings and gloves, washed her hands, and applied clean gloves. At 10:21 AM, LVN #1 cleaned and dried the resident's wound according to the physician's order, and then immediately packed the wound with collagen powder and calcium alginate and applied the foam dressing. LVN #1 did not perform hand hygiene and apply clean gloves before she applied medication and a clean dressing to the resident's wound, after cleaning the soiled wound. At 10:23 AM, LVN #1 washed her hands, applied clean gloves, washed a second surface wound on the resident's right buttock, patted it dry, and applied zinc cream. LVN #1 did not perform hand hygiene or change gloves between cleaning the wound and applying the medicated cream. During an interview on 08/21/2024 at 11:29 AM, LVN #1 stated cleaning the wound was considered a dirty procedure and the application of the medication and dressing was considered a clean procedure. LVN #1stated she should have cleaned her hands after she cleaned each wound and before she applied the medications on both of the resident's wounds and the clean dressing on the resident's coccyx wound. During an interview on 08/21/2024 at 12:59 PM, the Infection Preventionist (IP) stated the nurse should have cleaned her hands after she cleaned the wound, because it was considered a dirty Page 1 of 2 555244 555244 08/23/2024 Anberry Nursing and Rehabilitation Center 1685 Shaffer Rd Atwater, CA 95301

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few procedure. The IP stated the nurse should have cleaned her hands and applied clean gloves before she applied medication and clean gloves because it was considered a clean procedure. The IP stated the way the nurse completed wound care meant she wore dirty gloves during the clean procedure, and the potential risk was transmission an infection. During an interview on 08/21/2024 at 1:44 PM, the Director of Nursing (DON) stated she expected the nurse to perform wound care to wash her hands, apply clean gloves, remove the soiled dressing, wash her hands, and apply clean gloves and then clean the wound. The DON stated next, the nurse should have washed her hands and applied clean gloves before she applied medication and a clean dressing. The DON stated for the second wound, the nurse should have cleaned her hands, applied clean gloves and after cleaning the area and then applied the medicated cream. The DON stated cleaning a wound was considered a dirty procedure, and the application of medication and dressings, was considered a clean procedure. The DON stated potential risk was the nurse's contaminated hands could cause an infection in the wound. During an interview on 08/21/2024 at 1:48 PM, the Administrator stated she expected the nurse to clean her hands before she applied medications and dressings. She stated for the second wound she expected the nurse to wash her hands before she applied the medicated cream. The Administrator stated hand hygiene prevented the spread of infection. 555244 Page 2 of 2