Health inspection·September 16, 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 and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one of one resident (Resident #1) observed for infection control. Residents Affected - Few Facility failed to ensure Wound Treatment LVN A performed hand hygiene while providing wound care to Resident #1. This failure could place the residents at risk for infection. Findings include: Record Review of Resident #1's Other MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of hypertension, Peripheral Vascular Disease (the reduced circulation of blood to a body part other than the brain or heart), diabetes, non-pressure chronic ulcer of right heel and midfoot, non-pressure chronic ulcer unspecified part of right and left lower legs. Resident #1 had a BIMS of 15 indicating she was cognitively intact. Resident #1 required limited to extensive assistance with ADLs. Observation on 09/16/23 at 11:55 AM revealed Wound Treatment LVN A provided wound care to Resident #1. Wound Treatment LVN A was observed completing hand hygiene before care, then she informed the resident she was providing wound care. Wound Treatment LVN A sprayed wound cleanser on left lower leg wound and used gauze with the cleanser. Wound Treatment LVN A discarded the dirty gloves, and without hand hygiene she donned clean gloves. Wound Treatment LVN A put dressing of sliver alginate on wound. She continued with same gloves and used gauze to wrap the left lower leg wound and put a date on gauze dressing 09/16/23. Wound Treatment LVN A discarded the dirty gloves, washed hands and put new gloves on. Observations on 09/16/23 at 11:59 AM of the right lower leg wound care revealed Wound Treatment LVN A provided wound care to Resident #1's right lower left leg. Wound Treatment LVN A sprayed wound cleanser on right lower leg wound and used gauze with the cleanser. Wound Treatment LVN A discarded the dirty gloves, and without hand hygiene she donned clean gloves. Wound Treatment LVN A put dressing of sliver alginate on right lower leg wound. She continued with same gloves and used gauze to wrap the right lower leg wound and put a date on gauze dressing 09/16/23. In an interview on 09/16/23 at 12:10 PM with Wound Treatment LVN A revealed she should have washed hands after taking off gloves before putting on new gloves. Wound Treatment LVN A stated she did not complete hand hygiene when she changed gloves during wound care but stated she usually did complete Page 1 of 2 675611 675611 09/16/2023 The Villages of Dallas 550 E Ann Arbor Ave Dallas, TX 75216

F 0880 hand hygiene before putting on new gloves. Level of Harm - Minimal harm or potential for actual harm In an interview on 09/16/23 at 1:01 PM with the DON revealed she expected staff when changing gloves during wound care to wash hands after taking the dirty gloves off and before donning new gloves. She stated they have initiated an in-service on hand hygiene to all staff. The DON stated Resident #1 currently had an infection from her wound and was on antibiotics. The DON stated the Wound Treatment LVN A not completing hand hygiene during wound care for Resident #1 could place resident at risk of worsening of the wound. Residents Affected - Few Record review of the facility's policy reviewed October 2022, titled Hand Hygiene reflected, Purpose: Hand hygiene is one of the most effective measures to prevent the spread of infection .All personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infections to other personnel, residents and visitors .Use an alcohol-based hand rub containing at least 62% alcohol, or alternatively, soap .and water for the following situations .f. Before donning sterile gloves; g. Before handling clean or soiled dressings, gauze pads, .m. After removing gloves . 675611 Page 2 of 2