Health inspection·November 30, 2023

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, facility document review, and facility P&P review, the facility failed to implement the infection control practices designed to provide the safe and sanitary environment and help prevent the development and transmission of diseases and infections for two of sampled residents (Residents 1 and 2). Residents Affected - Few * The facility failed to ensure the staff practiced the contact isolation precautions when entering the room of one sampled resident (Resident 1) who was on contact isolation precautions * The facility failed to ensure the staff practiced the enhanced barrier precautions during high contact-care for one sampled resident (Resident 2) who was on enhanced barrier precautions. These failures posed the risk for the transmission of diseases-causing microorganisms. Findings: 1. Review of the facility's P&P titled Transmission-Based Precautions released on 6/2022 showed contact precaution is a method designed to reduce the risk of transmission of microorganisms by direct or indirect contact. Contact precautions are used for patients with known or suspected infections or evidence of syndromes that represent an increased risk of contact transmission. Increased risks include but are not limited to presence of excessive drainage, fecal incontinence, or other discharges from the body suggesting an increased potential for extensive environmental contamination and risk for transmission. The Infection Preventionist or designee reviews isolation status for patients daily. Further review of the facility's P&P showed the precaution-specific expectations: 1. Contact Precautions a. Hand hygiene - is the most important method of control to prevent transmission. b. Gloves c. Gowns - [NAME] a gown whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient. Medical record review for Resident 1 was initiated on 11/3/23. Resident 1 was admitted to the Page 1 of 4 555859 555859 11/30/2023 Kindred Hospital Brea D/P Snf 875 N Brea Blvd Brea, CA 92821

F 0880 facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm Review of Resident 1's Physician's Order Sheet for November 2023 showed an order to place Resident 1 on contact isolation for stool c-diff positive on 10/18/23. Residents Affected - Few Review of Resident 1's medical record showed Resident 1 was incontinent of bowel and required extensive assistance to total dependence in toilet use. On 11/3/23 at 0854 hours, Resident 1's room was observed with a special droplet/contact precaution sign posted by the Resident 1's door. The signage showed Special Droplet/Contact Precautions in addition to Standard Precautions, everyone including visitors, doctors, and staff must clean hands when entering and leaving the room, wear mask (fit tested N-95 or higher required when performing aerosol-generating procedures), wear eye protection (face shield or goggles), gown and gloves at the door, keep door closed. However, EVS 1 was observed mopping Resident 1's bathroom floor wearing only gloves with the door open opened. On 11/3/23 at 0854 hours, an interview was conducted with EVS 1 outside Resident 1's room. EVS 1 verified she was mopping Resident 1's bathroom floor wearing only gloves. EVS 1 further verified she should have worn proper PPE and closed the door when cleaning Resident 1's room. On 11/3/23 at 0855 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident 1 was on contact isolation for stool c-diff. RN 1 further stated for contact isolation residents, the staff should wear gloves and gown in mopping the bathroom for infection prevention. 2. According to the CDC, Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs (Multidrug- Resistant Organisms) to staff hands and clothing. MDRO may be indirectly transferred from residents-to-residents during these high-contact care activities. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: - Dressing - Bathing/showering - Transferring - Providing hygiene - Changing linens - Changing briefs or assisting with toileting - Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator - Wound care: any skin opening requiring a dressing Review of the facility's Enhanced Barrier Precautions, undated, signage showed everyone must clean hands before entering and after leaving room. All healthcare personnel must wear gloves and gown for 555859 Page 2 of 4 555859 11/30/2023 Kindred Hospital Brea D/P Snf 875 N Brea Blvd Brea, CA 92821

F 0880 the following high contact resident care activities: Level of Harm - Minimal harm or potential for actual harm - Dressing, bathing/showering - Transferring Residents Affected - Few - Changing linens - Providing Hygiene - Changing briefs or assisting with toileting - Device care or use: central line, urinary catheter, feeding tube, tracheostomy - Wound care: any skin opening requiring a dressing Medical record review for Resident 2 was initiated on 11/3/23. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's Physician's Order for October 2023 showed an order to place Resident 2 on enhanced precaution for CRE on 9/27/23. On 11/3/23 at 0943 hours, Resident 2's room was observed with enhanced standard precautions sign posted on Resident 2's door. The signage showed Enhanced Standard Precautions, everyone must perform hand hygiene before entering the room, anyone participating in any of these six moments must also: don gown and gloves. - Morning and evening care - Toileting and changing incontinence briefs - Caring for devices and giving medical treatments - Wound care - Mobility assistance and preparing to leave room - Cleaning and disinfecting the environment On 11/3/23 at 0943 hours, an observation of medication administration was conducted for Resident 2. LVN 1 checked Resident 2's GT placement wearing gloves. LVN 1 verified she should have donned gloves and gown before checking GT placement for infection prevention. On 11/3/23 at 0950 hours, an interview and concurrent record review was conducted with RN 1. RN 1 verified Resident 2 was on enhanced precaution isolation for CRE. RN 1 further stated for enhanced precaution isolation, the staff should wear gloves and gown when checking GT placement for infection prevention. On 11/30/23 at 0837 hours, an interview was conducted with the DON. The DON verified the staff were 555859 Page 3 of 4 555859 11/30/2023 Kindred Hospital Brea D/P Snf 875 N Brea Blvd Brea, CA 92821

F 0880 expected to perform hand washing, don gloves, and wear a gown to prevent spread of c-diff spores and during GTplacement for infection prevention. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555859 Page 4 of 4