Health inspection·October 12, 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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development of transmission of communicable diseases and infections for 1 ( Resident # 26) of 2 residents reviewed for infection control. Residents Affected - Few LVN B failed to perform hand hygiene while performing wound and incontient care for Resident #26. This failure could place residents at risk for cross contamination and infection. Findings include: Record review of Resident #26's face sheet, dated 10/11/2023, reflected a [AGE] year-old female who was admitted to the facility on 08/312022. Resident #26 had diagnoses which included Atrial Fibrillation (irregular heart rate), Hypertension (elevated blood pressure), Multiple Sclerosis (a disease in which the immune system eats away at the protective covering of nerves), Pressure ulcer of sacral region (an injury to skin and underlying tissue resulting from prolonged pressure on the skin) and Non Pressure Chronic Ulcer ( a wound caused by poor circulation to the lower extremities). Record review of Resident #26's significant change MDS , dated 7/25/2023, reflected a BIMS score of 13, which indicated the resident was cognitively intact. Record review of Resident #26 physician orders, dated 9/27/2023, reflected clean wound to right anterior ankle with wound cleanser, apply alginate pad and cover with dressing. Clean wound to left lateral foot with wound cleanser, apply alginate pad and cover with dressing. Clean wound to coccyx with wound cleanser, pack with alginate pad, cover with dressing. Clean blister to right lateral foot, cleanse with wound cleanser and cover with dressing. Observation on 10/11/2023 at 1:30 PM revealed LVN B preformed wound care on Resident #26. LVN cleaned and placed ordered wound care and dressing on right anterior ankle without changing gloves or preforming hand hygiene. LVN B then cleaned and placed ordered wound care on the left lateral foot without changing gloves or preforming hand hygiene. LVN B then removed gloves, preformed hand hygiene, and left the room to gather supplies. LVN B performed hand hygiene upon return to room. LVN B preformed incontinent care and changed gloves without preforming hand hygiene. LVN B removed soiled dressing to coccyx, cleaned the wound, applied ordered treatment and applied dressing without changing gloves or preforming hand hygiene. LVN B then changed gloves and preformed wound care to the right foot, removing the dressing, cleaning the wound and applying a clean dressing without changing gloves or preforming hand hygiene. Page 1 of 2 675884 675884 10/12/2023 Teague Nursing and Rehabilitation 884 Hwy 84 W Teague, TX 75860

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 10/11/2023 at 1:45 PM with LVN B, she stated she thought as long as she did care on the same resident it was not necessary to change gloves. LVN B stated she thought the policy might say to change gloves between dirty and clean. She stated she could imagine cross contamination could occur if gloves were not changed and proper hand hygiene was not preformed. Interview on 10/12/2023 at 1:00 PM with the DON, she stated her expectations was infection control and proper hand hygiene be used by staff when providing any resident care. When preforming wound care the gloves should be changed and hand hygiene done between removing the dirty dressing and wound cleaning and applying wound treatments and a clean dressing . Potential risk to resident is infection of the wound. Interview on 10/12/2023 at 1:30 PM with the ADM, he stated his expectation was all staff followed the infection control and hand hygiene policies when interacting with residents. He stated he expected the policy and procedures for resident care be followed. He stated failure to follow these policies could place the residents at risk of infection. Record review of the policy titled Dressing Dry/clean, dated September 2013, revealed .6. Put on clean gloves, loosen tape and remove soiled dressing, 7. Pull glove over dressing and discard into plastic or biohazard bag. 8. Wash and dry your hands thoroughly. 13. Put on clean gloves, 15. Cleanse the wound as ordered. 675884 Page 2 of 2