Health inspection·March 28, 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 designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of infection of communicable diseases and infections for one of six residents (Resident #1) reviewed for infection control. Residents Affected - Few CNA Z failed to perform hand hygiene during while providing incontinence care to Resident # 1. This failure could place the residents at risk for infection. Findings include: Record review of Resident #1's face sheet, dated 03/28/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included fracture of the patella (the bone at the front of knee joint), Alzheimer's disease (is a brain disorder that causes memory loss, thinking problems, behavior changes, and brain cell death) and dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). Record review of Resident #1's care plan, dated 12/21/23, reflected the resident was incontinent of bowel and blader and had an ADL self-care performance deficit related to cognitive impairment, and the intervention was for the resident incontinence care to be managed by staff. Observation on 03/28/24 at 09:44 AM revealed CNA Z provided incontinent care for Resident #1. CNA Z entered Resident #1's room, gloved without performing hand hygiene and proceeded to provide the residents with care. CNA Z unfastened the brief and cleaned the resident's front area, turned Resident #1 to her side, and removed the dirty brief. Resident #1 was soiled in urine. CNA Z then placed the dirty brief in the trash can and cleaned the resident's buttocks area. After cleaning the resident, without any form of hand hygiene or change of gloves, CNA Z applied the clean brief, turned the resident on her back and fastened the brief. After care, CNA Z completed hand hygiene. In an interview on 03/28/24 at 10:05 AM with CNA Z, CNA Z stated she was supposed to complete hand hygiene before and after care. CNA Z stated after cleaning the resident she was supposed to clean her hands and change gloves before applying the clean brief. CNA Z stated she was supposed to complete hand hygiene to prevent the spread of infection. CNA Z stated she completed a hand hygiene and infection control in-service about four months ago. In an interview on 03/28/24 at 11:49 AM with the ADON, she stated infection control was important Page 1 of 2 676483 676483 03/28/2024 Ventana by Buckner 8301 N. Central Expressway Dallas, TX 75201

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few during care. ADON A stated during incontinent care the staff were to use the hand sanitizer or wash hands if they were physically soiled. ADON A stated the staff were expected to complete hand hygiene before care and after care, she also stated during incontinent care the staff were supposed to change gloves and use hand sanitizer when taking off the dirty brief before applying the clean one. ADON A stated hand hygiene was to be completed for infection control. ADON A stated she was the infection preventionist and in-service on infection control was done twice a year. ADON stated it was her responsibility and the responsibility of the nurses in the units, ADON B and the DON to make sure the CNAs followed proper hand hygiene during residents' care. In an interview on 03/28/24 at 12:12 PM with the DON, she stated staff doing direct resident care were supposed to wash their hands before given care and afterward. She stated the CNAs were supposed to change glove, with hand hygiene when going from dirty to clean during incontinent care and perform hand hygiene before putting on the clean gloves. The DON stated hand hygiene was to be completed to prevent cross contamination from dirty to clean. The DON stated it was the responsibility of the nurses in the units, ADONs and DON to make sure the facility hand hygiene policy was followed by all the staff during resident care. Record review of the facility's policy, revised 01/23/24, and titled Hand Hygiene, reflected, Hand hygiene is the most important procedure for preventing the spread of infections. Hand hygiene should be performed: Upon arrival at the workplace and before going home. After using the toilet, blowing nose, and covering a cough or sneeze. Before and after eating. Before and after client contact. After removing gloves. Before invasive procedures. After touching contaminated items. 676483 Page 2 of 2