Health inspection·January 16, 2025

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, and record review the facility failed to maintain infection control practices when: Residents Affected - Few 1.Certified Nursing Assistant 1 (CNA 1) provided care to Patient 2 then proceeded to Patient 1s bedside without changing CNA 1s personal protective equipment (PPE) gown prior to initiating care for Patient 1. 2.CNA 2 placed clean linen intended for Patient 1 on top of a used soiled linen cart and proceeded to Patient 1s bedside to initiate care. These deficient practices had the potential to cause cross-contamination (the unintentional physical movement or transfer of harmful bacteria from one person, object, or place to another) of infectious pathogens (bacteria and microorganisms) from patient to patient and/or within the facility. Findings: During an observation on 1/15/25 at 10:30 AM, an Enhanced Barrier Precautions ([EBP] measures that use gowns and gloves to reduce the spread of infection) sign is posted outside Patient 1s door which indicated when entering the room, providers and staff must apply a gown and gloves. This is a double occupancy room with the patients distinguished by bed A and bed B. During an interview with the Infection Control Preventionist (IP) on 1/22/25 at 3:33 PM, IP indicated Patient 1 is on EBP which requires glove and gown use during high-contact patient care activities with patients who have wounds and/or indwelling (inside your body) medical devices or are infected or colonized (presence of with an infection where contact precautions (set of practices used to prevent the spread of infectious diseases) do not apply. EBPs are to be observed in addition to standard precautions. Regarding gown/PPE changes between patients, caregivers are educated/trained to not use the same PPE for care of more than one patient. Donning and doffing (putting on and removal) of PPE, as well as hand hygiene practices are part of core infection prevention principles that caregivers are required to get training on upon hire and on a yearly basis. Other educational opportunities on infection prevention practices are also offered all throughout the year in addition to education when a missed opportunity is observed. During an interview with CNA 1 on 1/27/25 at 20:15 PM, CNA 1 reports helping bed A (Patient 2) change Patient 2s urinary pad. CNA 1 then took the PPE gloves off, performed hand hygiene and put on new gloves. CNA 1 indicated the PPE gown was not changed. CNA 1 stated the gown was not changed due to not thinking clearly. CNA 1 stated this was due to bed B (Patient 1) requesting assistance. CNA 1 reports wanting to act quickly for bed B and forgot to change the gown. Page 1 of 2 555848 555848 01/16/2025 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with CNA 2 on 1/23/25 at 21:03 PM, CNA 2 reports remembering the incident. CNA 2 stated that the clean linen was grabbed for Patient 1. The linen was held in one hand and the dirty linen hamper with the other hand to bring the items closer to the bed. This is to assist throwing the linen in the hamper as it is removed. CNA 2 stated when walking into the room, bed A (Patient 2) began to cough. CNA 2 reports placing the linen on top of the soiled linen hamper and immediately went to help bed A (Patient 2) with repositioning in order to help maintain Patient 2s airway. After CNA 2 provided care, CNA 2 grabbed the linen and soiled linen hamper and started towards bed B ' s (Patient 1s) side of the room. CNA 2 reported there was no intention of using the items, but the family observed CNA 2 walking toward bed B (Patient 1) and became upset. CNA 2 reports apologizing and listening to the family member ' s concern. CNA 2 stated new linen was gathered and care continued for Patient 1. During review of the facilities policy and procedure (P&P) titled, SACC: Enhanced Barrier Precaution, dated 05/2024, the P&P indicated the purpose is to protect patients, caregivers, providers, and others by placing patients in EBP as indicated. EBP is based on the principle that Multidrug-resistant Organisms ([MDRO] germs that are resistant to more than one antibiotic) may be indirectly transferred (spread by multiple steps and not directly from one source to another) from patient-to-patient during high contact care activities. All caregivers including clinical and non-clinical personnel are expected to follow appropriate precautions during high contact patient care activities. PPE must be used consistently whenever performing any high contact patient care activities. The P&P defines high contact resident care activities as care activities that involves close physical or direct contact with the patient, patient environment, or devices such as during: Dressing Bathing or showering Transferring Providing hygiene Changing linens and/or collecting dirty laundry Changing briefs, or assisting with toileting Device care use such as central line, catheter, feeding tube, tracheostomy or ventilator care Wound care Rehabilitation or therapy services 555848 Page 2 of 2