**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to ensure 1 of 5 residents (R1) was offered, educated and/or provided the pneumococcal vaccination series as recommended by the Centers for Disease Control (CDC), who were reviewed for immunizations. Findings include: A CDC Adult Immunization Schedule by age topic, dated 11/21/2024, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was [AGE] years old, admitted on [DATE], moderately cognitively impaired and has the following diagnoses: anemia (low red blood cells and hemoglobin levels in the blood), hypertension (high blood pressure), hyperlipidemia (high levels of fat in the blood), Alzheimer's disease, dementia, and anxiety. R1's Order summary report dated 11/21/24, indicated on 2/13/24 the provider gave the following two orders: 1) May receive pneumococcal vaccinations if not already received. 2) May receive pneumovax if not already received. R1's Minnesota Immunization Information Connection (MIIC) vaccination record dated 11/19/24, indicated R1 received the pneumococcal polysaccharide PPSV23 on 11/1/1994. In accordance with the CDC recommendations R1 was eligible for a dose any of the following pneumococcal conjugate vaccines: PCV15, PCV20, or PCV21. R1's Point Click Care Immunizations form dated 11/21/24, indicated R1's had refused the vaccination, however there was no evidence of this refusal in R1's medical record. R1's Pneumococcal vaccinations consent form dated 2/14/24, indicated R1's daughter had asked the facility to check R1's records to verify if R1 had received the vaccination or not and did not refuse it. R1's medical record lacked any evidence of follow up regarding the consent form, communication with the family, verification of that data, or any documentation it was administered. On 11/21/24 at 08:59 a.m., the Infection preventionist/registered nurse (RN)-A, stated upon admission the facility would offer influenza, COVID-19, and pneumococcal vaccinations to eligible residents. The vaccination consent order would be sent to the provider to be signed, and then administered after receiving order and vaccination, then documented in the chart. RN-A confirmed R1's consent stated the family member wanted R1's record reviewed, and RN-A confirmed R1's record was never verified, nor the family followed up with. On 11/21/24 at 11:09 a.m., the director of nursing (DON) expected if a resident was eligible for any of the offered vaccinations, those would be provided as soon as the facility was able to. The DON confirmed no follow up was conducted regarding R1. The DON stated there had been a different DON and infection preventionist at the time, and the vaccination had been missed. The DON stated the importance of providing vaccinations to the residents to keep infection rates down, and to prevent the spread of infection within the resident population. On 11/21/24 at 1:11 p.m., R1's family member confirmed the facility had not followed-up regarding vaccinations until today (11/21/24), when they had called to offer it. R1's family member stated they would normally prefer to keep R1's vaccinations up to date. On 11/21/24 at 1:17 p.m., RN-A stated if a resident were to refuse a vaccination at the time of admission, they would go back and offer them again upon discharge, however, RN-A had not been offering them again for long term residents, such as R1. The Pneumococcal Vaccination Policy last modified July of 2023, indicated all residents who have never received a pneumococcal conjugate vaccine will be offered the vaccine upon admission and as needed in accordance with current CDC recommendations.

Based on observation, interview, and document review the facility failed to ensure enhanced barrier precautions (EBP)-(an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.) were implemented for management of a surgical wound to reduce the risk of infection to others for 1 of 1 resident (R2) reviewed for transfers. Findings include: R2's face sheet identified diagnoses of age-related osteoporosis with current pathological fracture of left lower leg and need of assistance with personal cares. R2's order summary dated 5/14/24, identified R2's incision was located on the left tibia was covered with dry dressings including xeroform/Adaptec, gauze fluffs, ABD, and ACE wrap. Keep dressing in place, clean and dry for two weeks. Change dressing only PRN (as needed) saturation greater than 60% every day shift. Incisions evaluated in clinic in 2-3 weeks and remove any staples or sutures as indicated. R2's Nurse Practioner (NP) visit note dated 5/15/24, identified R2 was hospitalized for Trauma Surgery with a closed fracture of left tibia and fibula due to a fall, R2 proceeded with an insertion of intramedullary rod left tibia and removal of hardware left tibia on 5/11/2024 and admitted to the facility for a short term stay on 5/14/24. R2's care plan dated 5/15/24, identified a focus, I require enhanced barrier precautions due to a surgical incision. Intervention indicated to follow enhanced barrier precautions in addition to standard precautions: wear gown and gloves during high-contact resident care activities. An additional focus dated 5/14/24 identified, I have limited physical mobility. Intervention included transfers, I require assist of two with a full lift and medium universal sling. During an observation on 5/22/24 at 5:08 p.m., upon entrance to R2's room an orange paper sign was hung on the wall to the right side of R2's door. Two red colored, STOP signs noted at the top on either side. Signage read: ENHANCED BARRIER PRECAUTIONS EVERYONE MUST: clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following activities. Dressing, Bathing/Showering, Transferring, changing linens, Providing Hygiene, Changing briefs or assisting with toileting. Device care or use: central line, urinary catheter, feeding tube, tracheostomy. Wound care: any skin opening requiring a dressing. Do not wear the same gown and gloves for the care of more than one person. The sign also had color pictures of hand cleanser, gloves, and gown. Nursing assistant (NA)-A and NA-B walked into R2's room without doing hand hygiene, did not utilize gloves or a gown. NA-A and NA-B transferred R2 from the bed to the recliner using a Hoyer lift. NA-A and NA-B did not perform hand hygiene after the transfer. During an interview on 5/22/24 at 5:16 p.m., NA-A and NA-B indicated an unawareness that EBP was to be used for high contact resident activities including transfers with R2. NA-B stated, I will go ask the nurse if we need to use EBP with R2. NA-B came back and stated, yes, we were supposed to use gown and gloves with the transfer for R2 due to R2 having a surgical wound to her left leg and indicated they should be using hand hygiene before and after cares with each resident and utilize gown and gloves with residents who are on EBP precautions to help prevent the spread of infection. During an interview on 5/22/24 at 5:23 p.m., interim clinical administrator stated, staff should be using EBP's with transfers for R2 due to a surgical wound on her left leg to help prevent the spread of infection. All residents with EBP have a sign clearly posted outside their room and staff should be looking for that and following our policy for EBP to help prevent the spread of infection. Facility policy, enhance Barrier Precautions Policy and Procedure, modified April 2024, identified a Purpose: PHS recognizes that our care center residents are at a higher risk of becoming colonized and infected with multidrug-resistant organisms (MDROs) as the prevalence of MDROs is higher in this care setting. As such, enhanced barrier precautions (EBP) which are a preventative approach to the use of personal protective equipment (PPE) to reduce opportunities of MDRO transmission during high-contact resident care activities will be implemented. Policy: 1. EBP (targeted gowns and gloves) are used in conjunction with standard precautions and will be implemented during high contact resident care activities for residents who: a. are known to be colonized or infected with CDC-targeted MDROs when Contact Precautions do not otherwise apply; and b. when caring for residents with wounds or indwelling medical devices even if the resident is not known to be colonized or infected with a MDRO. 2. EBP will be in place for the duration of a residents stay in the site or until resolution of the wound or discontinuation of the indwelling medical device for residents who are not colonized. 3. EBP is not intended to be a form of isolation and residents are not restricted to their rooms or limited from participation in group activities. 4. EBP should be followed when transferring residents in shared/common shower rooms and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility. 5. EBP does not need to be followed when transferring residents in the dining or activity rooms where contact is anticipated to be shorter in duration. Definitions: Wounds generally include chronic wounds and longer lasting wounds. This includes pressure injuries, venous stasis and diabetic ulcers, and unhealed surgical wounds, including new ostomies. This does not include short lasting wounds (e.g., skin tears). High-contact resident care activities include dressing, bathing/showering, transferring, providing hygiene, changing briefs, or assisting with toileting, changing linens, and indwelling medical device care or use (e.g., central line, dialysis port, urinary catheter, feeding tube, tracheostomy). Procedure: 1. Identify residents requiring EBP during the admission screening process and as needed. Specifically, review available key documents (e.g., H&P, discharge summary, physician progress notes, laboratory testing results) for documentation of known colonization of CDC-targeted MDROs, wounds or indwelling medical devices. 2. Review new notation of resident colonization of CDC-targeted MDROs, wounds or indwelling medical devices during the IDT process. 3. Upon identification of a resident with a known colonization of a CDC-targeted MDRO, wounds or indwelling medical devices: a. Notify and educate the resident or resident representative, IDT and QST, direct care staff. Provide re-education as needed. i. Resident and resident representative notification and education should be documented in the resident's record. The Enhanced Barrier Precautions Notification Letter may be used, however, should still be documented as given. b. Place an EBP sign on the resident's door. c. Ensure adequate supply of gowns and gloves are available in the resident's room. Note: This does not require an isolation cart to be placed outside the resident's room as this is a preventative measure that should have as little impact as possible on the resident's homelike environment. d. Ensure there is a trash can and hand hygiene supplies placed near the exit of the resident's room to discard the gloves and gowns prior to exiting the room. If the resident has a roommate, ensure staff are discarding the gloves and gowns, and performing hand hygiene before providing care to the second resident. e. Update the resident's care plan and care/team sheets. f. Update the infection control log and document the type of CDC-targeted MDRO the resident is known to be colonized with. 4. When performing high-contact resident care activities staff should: a. Perform hand hygiene. b. [NAME] gloves and a gown c. Complete the high contact activity d. Remove gloves and gown and dispose of in a trash can in the resident's room or if outside of the resident's room (e.g., shower/tub room or therapy gym) in a trash can contained within the area. e. Perform hand hygiene 5. If at any time a resident is requiring EBP they require additional precautions or isolation protocol, the more stringent precautions/protocol will apply.6. The Clinical Administrator, IP, or designee should audit staff adherence to this policy at random intervals using the Enhanced Barrier Precautions Observation Form.