Health inspection·June 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 observations, interviews, and record reviews, the facility failed to 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 disease and infection for 1 of 6 residents (Resident #17) reviewed for infection control, in that: Residents Affected - Few CNA A did not change her gloves or wash her hands after providing incontinent care for Resident #17 CNA A used a pillow that was on the floor to position Resident #17 CNA A used a brief on Resident #17 that she had picked up from the floor. These deficient practices could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #17's face sheet, dated 06/14/2024, revealed a [AGE] year-old female with an admission date of 05/17/2024 with diagnoses which included: Anxiety, depression, repeated falls, muscle weakness, limited mobility, and limitations to activities due to disability. Record review of Resident #17's admission MDS assessment, dated 05/20/2024, revealed Resident #17 has a BIMS score of 15, which indicated no cognitive impairment. Resident #17 was indicated to always being incontinent of bowel and bladder. Review of Resident #17's care plan, initiated 05/17/2024, revealed a focus of, The resident has bladder incontinence r/t Neurogenic bladder. Goal, the resident will remain free from skin breakdown due to incontinence and brief use through the review date. Intervention, Clean peri-area with each incontinence episode. Observation on 06/12/2024 at 12:20 PM revealed CNA A assisting Resident #17 to bed and providing the resident with incontinent care. After transferring Resident #17 in bed, CNA A completed hand hygiene and put on gloves and then gathered supplies for incontinence care. CNA A placed the supplies on the foot of the bed, the clean brief fell on the floor and CNA A picked up the brief from the floor and placed it back on the bed. Then CNA A informed the resident she was ready to complete incontinent care and positioned the resident on her side. While CNA A was positioning the resident a pillow fell from the bed to the floor and CNA A picked the pillow up from the floor and placed it on top of the sink. CNA A proceeded to clean the resident who was moderately soiled with urine. After cleaning Page 1 of 2 676410 676410 06/13/2024 Pure Health Transitional Care at Texas Health Pres 8200 Walnut Hill Lane Main 5 Dallas, TX 75231

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the resident without any form of hand hygiene CNA A applied the barrier cream on the resident's bottom area. Then the aide proceeded to applying the resident's clean brief, the one that was picked from the floor. CNA A then changed her gloves without any form of hand hygiene and repositioned the resident and used the pillow that she picked from the floor to elevate the resident's arm. Interview on 06/13/24 at 12:52 PM with CNA A, she stated she was in a hurry to finish from the room and that was the reason why she did not complete hand hygiene and change gloves while providing incontinent care to Resident #17. CNA A stated she was not supposed to use the brief and pillow that were on the floor because they were considered contaminated. CNA A stated she forgot and used the brief and pillow. CNA A stated she had completed a hand hygiene and infection control in-service about 1 month ago. CNA A stated she was supposed to complete hand hygiene and change gloves during incontinent care to prevent cross contamination. Interview on 06/13/24 at 01:04 PM with the DON, she stated while providing incontinent care the staff was to maintain infection control. The DON stated the brief, and the pillow were considered dirty because they were on the floor which was considered contaminated, and the staff was not supped to use them on the resident. The DON stated after cleaning the resident the staff was supposed to complete hand hygiene, after cleaning the resident and before touching the clean brief. The DON stated she expected the staff to maintain infection control. She stated infection control and hand hygiene in-service completed in the last three week. Review of the facility policy revised August 2019 titled Handwashing/Hand Hygiene reflected, This policy considers hand hygiene the primary means to prevent the spread of infections.2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. 676410 Page 2 of 2