Health inspection·November 13, 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, record review, and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for one of the residents (R# 1) of five that were reviewed for infection control and transmission-based precautions policies and practices, in that: Residents Affected - Few a.CNA A did not cleanse the catheter tubing while providing catheter care. These failures could place residents at risk for infection through cross contamination of pathogens. The findings included: Record review of R#1's Face Sheet dated 11/13/2023, admitted [DATE], documented a [AGE] year-old male with the following diagnoses of: Parkinson's disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), dysphagia (swallowing difficulties), chronic ischemic heart disease, benign prostatic hyperplasia (age-associated prostate gland enlargement that can cause urination difficulty). Record review of R #1's MDS dated [DATE], revealed R#1 had a 02/15 BIMS score documenting a severe cognitive impairment. R#1 was coded to have an indwelling catheter. R#1 also required extensive assistance of staff to assist in activities of daily living. Record review of R #1's Comprehensive Care Plan date initiated 10/19/2023 revealed, R#1 has a foley catheter and was at risk for increased UTI's. due to urinary retention. Interventions: change the foley catheter, tubing, and bag per order. Ensure leg strap or other method to secure catheter is in place unless contraindicated. Monitor urine for odor, color, sediments and amount of urine, and report abnormalities to MD. Encourage PO and fluid intake within dietary limits. Keep tubing/bag below the bladder, do not kink tubing. Perform catheter care per order. Record review of R#1's Physician Order dated 03/09/2023 revealed: Indwelling catheter care every shift with soap and water or may use wipes as appropriate/ desired by patient. During an observation on 11/13/2023 at 12:53PM, while providing catheter care on R#1, CNA A cleaned the penile area but did not cleanse from the meatus (opening) outward for at least 4 inches of catheter tubing. Page 1 of 2 675312 675312 11/13/2023 Palma Real 1220 Loop 459 Mathis, TX 78368

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/13/2023 at 1:14PM, CNA A stated she was given a competency check off yearly on foley care. CNA A stated she was nervous and should have cleaned the catheter tubing to prevent infection. CNA A stated by not cleaning the catheter tubing, R#1 could have potentially been exposed to infection, which could have led to a urinary tract infection which can affect the well-being of R#1. CNA A stated the urinary discharge could potentially infiltrate the urinary system and cause a terrible infection which could affect R#1's safety. CNA A stated she normally cleans the catheter but forgot this time. CNA A stated she was last in-serviced about foley catheter care a couple of weeks ago. During an interview on 11/13/2023 at 1:28PM, the DON stated CNA A was taught to cleanse penile area, followed by cleaning the tubing. The DON stated CNA A should have cleansed the catheter tubing as a standard of care to promote infection control. The DON stated by omitting the catheter tube cleaning, the well-being of R#1 could have been compromised. The DON stated R#1 potentially could have contracted an infection, and if not treated, R#1 could experience altered mental status, frequent urination, or worse sepsis. The DON stated all clinical staff are given competency skills checkoffs via online education portal, which includes foley catheter care. The DON stated peri-care (Perineal Care) in-services are conducted periodically and as needed. Record Review of the facility's Perineal Care Protocol, dated 02/2022, stated: If catheter is present, stabilize the catheter, then gently wipe the catheter tubing with new wipe from the meatus outward for at least 4 inches of tubing. Record Review of the facility's Nurse Aide Proficiency Audit dated 08/14/2023 documents a passing evaluation regarding infection control and catheter care for CNA A. Record review of the facility's Peri-care (Perineal Care) In-service Training Report dated 11/10/2023, reflected CNA A was in attendance. 675312 Page 2 of 2