Health inspection·February 2, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to meet the care needs related to the tracheostomy care for one of the three sampled residents (Resident 2). Residents Affected - Few * The facility failed to ensure the tracheostomy care was provided to Resident 2 as per the facility's P&P. This failure posed the risk for not keeping the stoma area clean and being susceptible to infection. Findings: Review of the facility's P&P titled Trach Care dated 5/2014 showed the respiratory care staff along with nursing staff will provide proper and correct tracheostomy/stoma care in order to keep stoma area clean, free of secretions, and less susceptible to infection. The procedure showed the following: - to dampen the applicators and gauze with hydrogen peroxide (mild antiseptic) and swab the secretions from stoma/trach area until clean. Rinse with sterile water. On 2/1/24 at 1200 hours, a tracheostomy care observation of Resident 2 with RT 2 was conducted. RT 2 prepared a sterile table with the trach care kit. RT 2 then washed his hands and donned sterile gloves, with RT 3 assisting in repositioning and loosening Resident 2's tracheostomy tie. RT 2 removed Resident 2's old sponge covering the stoma, then removed the trach tube, and placed a new trach tube. RT 2 then covered the stoma with a clean dry gauze, then applied a dated new tie to secure the tracheostomy. RT 2 stated he forgot to bring the hydrogen peroxide to mix with sterile water to clean the skin around the stoma before inserting the new tracheostomy tube and covering with a dry gauze. Medical record review was initiated on 2/2/24. Resident 2 was admitted to the facility on [DATE]. Review of the physician's orders showed the following orders dated 2/2/23: - to change trach tube tie after bath in AM and PRN - to change trach 5.5 Peds [NAME] uncuffed monthly and as needed for airway patency On 2/1/24 at 1505 hours, an interview with the lead RT was conducted. The lead RT stated skin around the tracheostomy stoma should be cleansed with 3% hydrogen peroxide mixed with ½ strength sterile water before covering the tracheostomy stoma with a gauze and securing with new dated tie. Page 1 of 3 555730 555730 02/02/2024 Foothill Regional Medical Center D/P Snf 14662 Newport Avenue Tustin, CA 92780

F 0684 The lead RT further stated not cleaning the skin around stoma was a concern for infection prevention. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555730 Page 2 of 3 555730 02/02/2024 Foothill Regional Medical Center D/P Snf 14662 Newport Avenue Tustin, CA 92780

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Potential for minimal harm Based on observation, interview, and facility record review, and facility P&P review, the facility failed to ensure the hand hygiene practices were performed after removal of gloves as per the facility's P&P. This failure had the potential for transmission of disease-causing microorganisms and infections to the residents. Residents Affected - Some Findings: Review of the facility's P&P titled Infection Control dated 5/2014 showed Universal Precautions shall be used for all residents: * Wash hands after contact with blood/body fluid/mucous membranes/non intact skin. * After removal of gloves. On 2/1/24 at 0946 hours, an observation and concurrent interview with RT 1 was conducted. RT 1 stated it was the facility's protocol to change the tracheostomy tie every day after the resident's shower and tracheostomy tube every first of the month. RT 1 cleaned Resident 1's skin around the stoma with water mixed with hydrogen peroxide, deflated the cuff, then changed gloves without performing hand washing in between. RT 1 removed the tracheostomy tube and inserted a new tube, covered stoma with a clean gauze, discarded the used tubing, and performed handwashing. On 2/1/24 at 0955, an interview with RT 1 was conducted. RT 1 verified no handwashing was performed in between glove changing during tracheostomy care. RT 1 further stated this may be a concern on infection prevention. On 2/1/24 at 1140 hours, an interview with the Nurse Manager was conducted. The Nurse Manager stated handwashing was observed every time a facility staff entered the residents' room, when hands were visibly soiled, changing diapers, suctioning, and in between changing of gloves for infection prevention. The Nurse Manager further stated RT 1 should have washed hands in between changing of gloves during tracheostomy care. 555730 Page 3 of 3