Health inspection·November 30, 2022

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 did not maintain an infection prevention 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 (CNA A) of three staff members reviewed. Residents Affected - Few -CNA A failed to change her gloves and perform hand hygiene after providing incontinence care and prior to assisting Resident #4 with dressing and positioning back into her wheelchair. This failure could places residents requiring incontinent care at risk for cross-contamination and infection. Findings included: Observation of incontinence care on 11/29/2022 at 11:20 a.m. provided by CNA A revealed the ST was present and assisted with translation during the procedure. CNA A and ST washed their hands at the sink in the Resident #4's bathroom and donned gloves. CNA A placed a gait belt around the resident's waist. Resident sat in her wheelchair, which was rolled into the bathroom. CNA A assisted resident to stand, pivot and sit down on the toilet using the gait belt. Prior to sitting down, the CNA A pulled residents brief down. CNA A reported the brief was dry. Resident urinated while sitting on the toilet. CNA A assisted resident to stand up, and the resident was encouraged to hold onto a grab bar across from the toilet. CNA A used wipes to clean resident's peri and buttock area, using one wipe per swipe before discarding, and wiping from front to back. CNA A pulled residents brief and pants up. Resident was assisted back into her wheelchair by CNA A and ST. CNA A removed the gait belt from the resident's waist. CNA A removed her gloves, used hand sanitizer, and provided hand sanitizer to the resident and S.T. CNA A washed her hands at the sink in the residents bathroom. In an interview with CNA A on 11/29/22 at 11:30 a.m. she said she should have removed her gloves and sanitized her hands after she pulled Resident #4's pants up. CNA A said a potential problem with not removing her gloves after providing incontinence care was the possibility of putting germs in places she should not put them. CNA A said she had received training on hand hygiene within the last 2 months. In an interview with the DON on 11/29/2022 at 2:47 p.m. revealed her expectations regarding hand hygiene during incontinent care included gloves be changed anytime they were soiled, anytime they might be soiled, and anytime there was a question about them possibly being soiled. The DON said hand hygiene should be performed anytime you move from a dirty to a clean area. She said a potential problem with hand hygiene not being performed according to facility policy during incontinent care was an infection control issue; cross-contamination to that resident, or the spread of infection to others. Page 1 of 2 675560 675560 11/30/2022 Lake Village Nursing and Rehabilitation Center 169 Lake Park Rd Lewisville, TX 75057

F 0880 Level of Harm - Minimal harm or potential for actual harm The DON said skill checks and in-servicing were done with staff when asked about who was responsible for ensuring that hand hygiene policy was being followed. In an interview with the DON on 11/30/22 at 9:00 a.m., she reported in-service training had been initiated on 11/29/22 regarding Hand Hygiene. Residents Affected - Few Record review of the in-service related to Hand Hygiene revealed 18 staff members had signed their names as evidence they had attended the in-service. Record review of the facility policy Hand Hygiene, dated 10/2022, revealed Hand hygiene is one of the most effective measures to prevent the spread of infection. Studies show that effective hand decontamination can significantly reduce the rate of healthcare associated infection .2. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: h. Before moving from a contaminated body site to a clean body site during resident care .j. After contact with blood or bodily fluids . 675560 Page 2 of 2