Health inspection·September 23, 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 resident (Resident -R# 1) of five residents that were reviewed for infection control and transmission-based precautions policies and practices, in that: Residents Affected - Few The facility failed to ensure LVN A performed hand hygiene and removed her contaminated gloves prior to the commencement of perineal care after she touched multiple surfaces. This failure could place residents at risk for infection through cross contamination of pathogens. The findings included: Record review of R #1's Face Sheet dated 09/23/2023, admitted on [DATE] revealed a [AGE] year-old female with the following diagnoses of: acute kidney failure, Parkinson's disease, epilepsy, congestive heart failure, and morbid (severe)obesity. Record review of R #1's MDS assessment dated [DATE] documented a BIMS score of 14 - cognitively intact. The assessment indicated R #1 required extensive dependency of staff to assist in bed mobility, transfers, toilet usage, and personal hygiene with two-person physical assist. Record review of R #1's Comprehensive Care Plan date initiated 09/08/2023 revealed, the focus that the resident had functional, bladder incontinence. Goal, the resident will decrease frequency of urinary incontinence through the next review date. Interventions, establish voiding patterns, monitor/document for s/sx UTI; pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change eating patterns. Provide peri-care and/or assistance after each incontinent episode. During an observation on 09/22/2023 at 3:35PM LVN A washed her hands for 24 seconds, applied gloves, retrieved a clean brief and a package of wipes, then proceeded to pull the light string to turn light on, followed by retrieving the bed remote to lower the head of bed and elevated the bed to LVN A's waist level. LVN A then removed R #1's blanket and detached R #1's brief. LVN A retrieved perineal wipes and commenced perineal cleaning, using the same initial gloves, that touched multiple surfaces. LVN A continued peri care without performing hand hygiene or glove changes. During an interview on 09/22/2023 at 3:45PM LVN A stated she should have performed hand hygiene and Page 1 of 2 675773 675773 09/23/2023 Brookdale Trinity Towers 317 N Carancahua Corpus Christi, TX 78401

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few gloves change after touching multiple surfaces as a precautionary measure of preventing infection. LVN A stated she potentially could have introduced microorganism which could potentially have caused a UTI or worse turned into sepsis. LVN A stated she did not recall if the facility provided an in-services/education or competency checkoffs, as an LVN, regarding perineal care. During an interview on 09/22/2023 at 5:49PM, the DON stated LVN A should have removed contaminated gloves and performed hand hygiene after LVN A touched multiple surfaces. The DON stated LVN A should have removed contaminated gloves and performed hand hygiene to prevent potential contamination of microorganisms that live on surfaces. The DON stated microorganisms can cause UTIs which could lead to sepsis, and sepsis could lead to death. The DON stated perineal competencies with educational literature, are administered to the clinical staff by ADONs, upon hire, yearly, and as needed. The DON stated LVN A was given a competency check off 05/05/2023. Record review of the facility's perineal care skills competency checkoff dated 09/22/2023, revealed LVN A was administered an on-the-spot in-service on perineal care. Record review of the facility's perineal care skills competency dated 05/05/2023, revealed LVN A was given a perineal care skills competency checkoff. Record review of the facility's Handwashing/Hand hygiene policy and procedures effective date 10/2015 and last revision date 01/2021 revealed, G. CDC recommends using Alcohol based hand sanitizer with 60-95% alcohol in healthcare settings. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water during routine resident care. 12. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; 13. After removing gloves; 675773 Page 2 of 2