Health inspection·April 13, 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 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 infection for 1 of 4 residents (Resident #1) reviewed for infection. Residents Affected - Few -The facility failed to ensure CNA A performed hand hygiene during incontinent care on Resident #1. This failure could lead to the spread of infection to residents, resident illness, and/or resident distress. Finding include: Record review of the admission sheet (undated) for Resident #1 revealed an [AGE] year old female admitted to the facility on [DATE] with diagnoses which included cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), hypertension (a condition in which the force of the blood against the artery walls is too high) and polyosteoarthritis ( arthritis in five or more joints at the same time). Record review of Resident #1's Entry MDS, dated [DATE], revealed there was no section for BIMS score, functional status, urinary incontinence, and bowel incontinence. Record review of Resident #1's care plan, initiated 04/12/24 revealed the following: Focus: The resident has little or no activity involvement r/t resident wishes not to participate Goal: The resident will express satisfaction with type of activities and level of activity involvement when asked through the review date. Interventions: Invite/encourage the resident's family members to attend activities with resident in order to support participation. Observation on 04/13/24 at 10:33a.m., revealed CNA A provided Resident #1 with incontinence care. CNA A removed Resident #1's brief and tucked it under the resident's buttocks. CNA A assisted Resident #1 to turn her onto her left side in order to clean her buttocks. Resident had a large bowel movement. CNA A without removing her soiled gloves, tucked the clean brief under the resident's buttocks. CNA A completed perineal care and with the same soiled gloves on, touched the Resident's clean shirt, brief, sheet, and blanket. In an interview on 04/13/24 at 11:02a.m., with CNA A, she said she did not recall doing CNA Page 1 of 2 676258 676258 04/13/2024 Memorial City Nursing and Rehabilitation Center 1341 Blalock Houston, TX 77055

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few competency checks for incontinent care. CNA A said her actions in not performing hand hygiene while changing gloves could result in cross contamination. She said she had completed in-service on infection control on Monday 4/8/24. She said the Unit Manager spot check her performing incontinent care 2 months ago. She said she could not recall the exact date. In an interview on 04/13/24 at 12:07 p.m., with the DON and the Administrator, the DON said CNA should have either washed or sanitized her hands after touching a dirty area prior to moving to a clean area when performing incontinent care. She said these failures were risk for infection control. She said staff received in-service on infection control monthly. She said CNAs were provided training and competency check offs quarterly and as needed. The DON said the Unit Manager randomly spot-checked CNAs. In an interview on 04/13/24 at 12:29 p.m., with the Unit Manager, she said she spot checked the CNAs that worked on Monday 4/8/24 with setting up the supplies, observing peri care and hand hygiene. She said the CNAs should sanitize their hands in between gloves change and wash hands if visibly soiled. Record review of facility's In-service Training Reported dated 04/13/24 revealed the Nursing department was in-serviced on Infection Control: Handwashing, Incontinent care. CNA A was listed as being part of this inservice. Record review of the facility's Hand Hygiene policy dated 10/24/22 revealed read in part: .Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. 6. Additional considerations: · a. The use of gloves d6es not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . Record review of the Infection Control policy dated 5/13/23 revealed read in part: .Policy: This facility has established and maintains 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 as per accepted national standards and guidelines . 676258 Page 2 of 2