Health inspection·September 26, 2024

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 prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 (Residents #1) of 3 residents reviewed for infection control in that: Residents Affected - Few 1. CNA A failed to change their soiled gloves and wash hands during incontinent care for Resident #1. These failures could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Review of Resident #1's EHR on 09/24/24 revealed the resident was a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses including Polyarthritis (arthritis that affects all joints),and mixed incontinence (both urine and bowel incontinence). Review of Resident #1's quarterly MDS assessment, dated 7/02/24, reflected a BIMS score of 9, indicating the resident was moderately impaired cognitively, and able to make decisions. Her functional status indicated she needed two staff to complete her activities of daily living, to include incontinent of bowel and bladder. Observation on 04/24/24 at 11:44 a.m., revealed CNA A and NA B donned clean gloves. CNA A, with the help of NA B, positioned Resident #1 on her back. CNA A unfastened the resident's brief tabs and wiped the pubic area with a disposable wipe, discarded the wipe, then she wiped the folds of the groin inguinal (abdomen) area using wipes. CNA A, with assistance of NA B, repositioned Resident #1 on her left side and cleaned her buttocks area, which was soiled with urine, then removed the brief and placed it in a trash bag. CNA A placed a clean brief on Resident #1 and fastened it. CNA A continued with care for Resident #1 without discarding her soiled gloves. She pulled the resident's dress down and pulled the cover up over the resident. CNA A and NA B then removed their dirty gloves disposing of them in the trash bag, leaving the room after washing their hands. Interview on 09/24/24 at 12:00 p.m., CNA A stated she never changed her gloves between dirty and clean, while performing incontinent care on Resident #1. CNA A stated she just washed her hands before and after care. NA B stated she was being trained and she did touch the resident only to repositioned her, but she knew to change gloves and wash her hands but did not say anything to CNA A. CNA A and NA B stated by not changing their gloves and sanitizing their hands they could spread germs to Page 1 of 2 676123 676123 09/26/2024 Fairfield Nursing & Rehabilitation Center 420 Moody St Fairfield, TX 75840

F 0880 other residents. Level of Harm - Minimal harm or potential for actual harm Interview on 09/25/24 at 10:45 a.m., the DON stated that her expectation was that staff would sanitize their hands prior to putting on and after taking off gloves. She stated the staff should be changing their gloves when they go from dirty to clean and sanitizing in between. If the staff changes gloves multiple times, they must sanitize their hands with soap and water or hand gel between each time. The DON stated she thought she would have to do some further training. Residents Affected - Few Review of facility's Policies and Procedure titled: Perineal Care, dated May 2022, reflected the following: .The purpose: aims to maintain the resident's dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition . procedure content: .10) perform .hand hygiene, 11) [NAME] gloves, instructions on performing incontinent care provided .24) doff gloves, 25) perform hand hygiene, placing on new gloves if necessary, 26) provide resident comfort and safety by reclothing . straightening bedding, adjusting the bed . important points: doffing and discarding of gloves are required if visible soiled, always perform hand hygiene before and after glove use 676123 Page 2 of 2