**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observations, record review, and staff interview, it has been determined that the facility failed to provide a safe and sanitary environment to help prevent the transmission of infections relative to disinfecting glucometers (a device used to monitor blood glucose) for 3 of 3 residents observed who require blood glucose monitoring, Resident ID #s 8, 9, and 14; and 2 of 2 residents reviewed relative to contact precautions, Resident ID #s 14 and 18; and the handling of soiled linen for 1 of 1 laundry room observed. Findings are as follows: 1. According to the facility's policy last revised March of 2015 titled, diabetes - care of equipment states in part, .5. If a glucometer is to be used for one resident and then reused for another, the device must be cleaned and disinfected between uses .Follow the glucometer manufacturer's recommendations for cleaning . Review of the glucometer manufacturer's QA/QC (Quality Assurance/Quality Control) Reference Manual titled, ASSURE PLATINUM BLOOD GLUCOSE MONITORING SYSTEM, states in part, GUIDELINES FOR CLEANING AND DISINFECTING THE ASSURE PLATINUM METER. To minimize the risk of transmitting blood-borne pathogens, the cleaning and disinfecting procedure should be performed as recommended in the instructions below .The meter should be cleaned and disinfected after use on each patient. The cleaning procedure is needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing the disinfecting procedure. The disinfecting procedure is needed to prevent the transmission of blood-borne pathogens .Clean and disinfect the meter following step-by-step instructions .Option 1 Obtain a commercially available EPA [Environmental Protection Agency]-registered disinfectant detergent or germicide wipe .CLEANING AND DISINFECTING PROCEDURES. NOTE Two disposable wipes are needed for each cleaning and disinfecting procedure; one wipe for cleaning and a second wipe for disinfecting .CLEANING .Step 3 Wipe surface of the meter to clean blood and other body fluids .Step 4 Dispose of the used towelette in a trash bin. The meter should be cleaned prior to each disinfection step. DISINFECTING STEP 5 Pull out 1 new towelette and wipe the entire surface of the meter horizontally and vertically to remove bloodborne pathogens . Review of a document dated 8/18/2023 addressed from the EPA to a Clorox representative regarding the Clorox product with EPA Registration Number 5813-79, states in part, .DIRECTIONS FOR USE .TO CLEAN [HARD, NONPOROUS SURFACES] .Wipe surface clean with this product. Let air dry .TO DISINFECT .[Use to disinfect] hard, nonporous surfaces: For visibly soiled surfaces, clean first .Special instructions for Use Against .HCV [Hepatitis C Virus] .This product kills HCV .on a precleaned hard, nonporous surfaces/objects previously soiled with blood/body fluids in health care settings .Cleaning Procedure: Blood and other bodily fluids must be thoroughly cleaned from surfaces and other objects before applying this product . a) Record review revealed Resident ID #14 was readmitted to the facility in September of 2023 with diagnoses including, but not limited to, chronic viral hepatitis C and type II diabetes. Additionally, his/her blood sugars are monitored four times a day. b) Record review revealed Resident ID #8 was readmitted to the facility in February of 2022 with a diagnosis including, but not limited to, type II diabetes. Additionally, his/her blood sugars are monitored four times a day. c) Record review revealed Resident ID #9 was admitted to the facility in September of 2023 with a diagnosis including, but not limited to, type II diabetes. Additionally, his/her blood sugars are monitored four times a day. During surveyor observations on 11/9/2023 at 11:39 AM during the medication administration task with Registered Nurse (RN), Staff B, the following observations were made: - Staff B obtained Resident ID #9's blood sugar. Staff B then used one Clorox wipe to clean the glucometer. Staff B did not utilize a second Clorox wipe to disinfect the glucometer as per the manufacturer's guidelines, prior to proceeding to the next resident. - Staff B obtained Resident ID #8's blood sugar with the same glucometer used for Resident ID #9. Staff B was observed using his gloved hands to remove the used test strip, which was contaminated with blood, from the glucometer. At this point, the surveyor informed Staff B, that there was a test strip release button on the glucometer that allows the strip to be ejected without having to manually remove it. Staff B returned to the nursing cart located at the nurses' station and proceeded to use one Clorox wipe to clean the glucometer. Staff B did not utilize a second Clorox wipe to disinfect the glucometer as per the manufacturer's guidelines and proceeded to the next resident. - Staff B obtained Resident ID #14's blood sugar using the same glucometer that was previously used on Resident ID #s 8 and 9. Staff B exited the room, and was noted to be holding the uncleaned, non-disinfected glucometer with the contaminated test strip still in the glucometer, which was observed to be in direct contact with the clean, unused blood glucose monitoring supplies which were contained in a small basket used for multiple residents. Staff B proceeded to walk through the facility passing the common area and dining room with several residents present, until he returned to the nurses' station where he placed the basket atop the nursing cart. Again, it was noted the glucometer and contaminated test strip were in direct contact with the basket of clean blood glucose monitoring supplies. With a gloved hand, he manually removed the contaminated test strip from the glucometer and disposed of it in the sharps container. Without changing gloves, he grabbed the Clorox wipes cannister and removed a wipe, and proceeded to wipe the glucometer with the now contaminated wipe using the same gloves that were used to manually remove the contaminated test strip, which had just been used to obtain a blood sugar from Resident ID #14, who is positive for Hepatitis C. After using the one contaminated Clorox wipe, he set down the glucometer. Staff B was not observed to utilize a second Clorox wipe to disinfect the glucometer as per the manufacturer's guidelines. Additionally, a surveyor observation on 11/9/2023 at 1:37 PM revealed the glucometer that was used to assess the above-mentioned resident's blood sugars, after having already been cleaned with one Clorox wipe, revealed an accumulation of dark colored debris in 4 separate areas of the battery cover latch. During a surveyor interview on 11/9/2023 at 1:54 PM with the Director of Nursing Services (DNS), in the presence of 3 additional surveyors, she revealed that Staff B had used the wrong wipes for cleaning and disinfecting the glucometer. She further revealed that PDI wipes, which contain bleach, should've been used. Additionally, she was unsure if the Clorox wipes used by Staff B are effective at killing blood borne pathogens. During a surveyor interview on 11/9/2023 at 2:52 PM with Staff B, he acknowledged that he manually removed the contaminated test strip from the glucometer and without changing his gloves, proceeded to use a Clorox wipe to clean the glucometer. He further revealed he was unsure if the Clorox product was effective at killing blood borne pathogens. Additionally, he revealed he had utilized the same Clorox product to wipe the glucometer when assessing multiple resident's blood sugars earlier that day. During a follow up surveyor interview on 11/10/2023 at 1:59 PM with the DNS, she revealed that test strips should be disposed of immediately after use and that dirty items should not be mixed with clean supplies. She was unable to provide evidence that staff provided a safe and sanitary environment to help prevent the transmission of infection and blood borne pathogens. As a result of the facility's failure to follow its own diabetic equipment cleaning and disinfection policy relative to glucometers, and more specifically, the glucometer's reference manual specific to the cleaning and disinfection process, placed all residents who require blood glucose monitoring at increased risk for the transmission of blood borne pathogens. Furthermore, Staff B's multiple failures including improperly cleaning and disinfecting the multi-use glucometer by not utilizing two wipes as indicated, mixing dirty and clean supplies, and utilizing a contaminated wipe to clean and disinfect the glucometer, placed these residents at increased risk for contracting blood borne pathogens. 2. Review of a facility policy titled, guideline for Management of MDROs [Multidrug resistant organism] dated 1/18, states in part, .discontinuing Contact Precautions [wear a gown and gloves for all interactions that may involve contact with the resident or the resident's environment] .Contact Precautions should be used for the duration of the stay in the setting in which they were first implemented .In general it is reasonable to discontinue contact precautions when three or more surveillance cultures for the target MDRO are repeatedly negative over the course of week or two in a patient who has not received antimicrobial therapy for several week . Further review of the facility policy titled, guidelines for Management of MDROs states in part, .MRSA [Methicillin resistant Staphylococcus aureus infection; an infection is caused by a type of staph bacteria that's become resistant to many of the antibiotics] - RIDOH [Rhode Island Department of Health] recommends that Contact precautions may be discontinued when: There is documentation of 2 consecutive negative MRSA screens from previously positive sites .Screens are to be obtained no sooner than 72 hours after the completion of decolonization and/or treatment has been completed . a. Record review revealed Resident ID #18 was admitted to the facility in March of 2023 with a diagnosis including, but not limited to, MRSA. Review of a hospital Discharge summary dated [DATE] revealed the resident was positive for MRSA in a right lower extremity wound and was being treated with Bactrim (antibiotic). Review of a progress note dated 3/14/2023 states in part, .also, resident tested positive for MRSA of the nares while in the hospital and treatment was not offered/completed. Dr [doctor] .aware and resident with new order for Bactroban [a medication to treat/decolonize a resident with MRSA in the nares or decolonized MRSA] to nares BID [twice daily] topically for 5 days . Review of a care plan dated 3/8/2023 and updated 6/27/2023 revealed the resident has MRSA in the nares with interventions that include, but are not limited to, standard universal precautions in place. Review of the March 2023 Medication Administration Record revealed the following orders: - Bactrim, twice daily, with a start date of 3/8/2023 and an end date of 3/11/2023. - Bactroban, apply to nares two times daily, for 5 days, with a start date of 3/15/2023 and an end date of 3/19/2023. Record review failed to reveal evidence that at least two negative MRSA screens were obtained for the nares. Record review failed to reveal evidence that at least two negative MRSA screens were obtained for the right lower extremity wound. During surveyor observations on the following dates and times revealed the resident had no signage posted outside his/her room indicating s/he was on contact precautions and did not have an isolation bin containing personal protective equipment (PPE) supplies outside his/her room: - 11/7/2023 at 9:13 AM - 11/8/2023 at 8:07 AM - 11/9/2023 at 10:42 AM Review of the CENTER FOR EPIDEMIOLOGY & INFECTIOUS DISEASES Guidelines for the Management of Methicillin Resistant Staphylococcus Aureus in Rhode Island Long-Term-Care Facilities (2007) revealed that routine decolonization for MRSA in the nares is not recommended for long term care facility residents. It further revealed that decolonization attempts would be appropriate for residents admitted from the hospital with decolonization procedures already underway. Additionally, to remove a resident from contact precaution following decolonization would require the following criteria to be met: Contact precautions may be discontinued when there is documentation of two (2) consecutive negative MRSA screens from previously positive sites. Screens should be obtained no sooner than 72 hours after completion of decolonization and/or treatment of infection and screens should be at least five days apart. During a surveyor interview on 11/10/2023 at 11:17 AM with the DNS, she acknowledged that the resident's lower extremity wound, and nares were not re-cultured following the completion of the antibiotic treatment, per facility policy and Center for Epidemiology and Infectious Disease guidelines. Further, she was unable to provide evidence that the resident's lower leg extremity wound, or nares were re-cultured following the completion of antibiotic treatment. b. Review of a facility policy titled, Isolation states in part, .Contact precautions .use Contact Precautions for residents known or suspected to be infected with microorganism that can be easily transmitted by direct or indirect contact .The above includes organisms such as MRSA .Contact Precaution Procedure .require the use of appropriate PPE [Personal Protective Equipment], including a gown and gloves upon entering the contact precaution room . Record review revealed Resident ID #14 was readmitted to the facility in September of 2023 with a diagnosis including, but not limited to, non-pressure chronic ulcer of the right foot. Record review of a progress note dated 10/9/2023 at 10:56 AM revealed in part that the resident's right foot wound was cultured and tested positive for MRSA and s/he was placed on contact precautions. Record review revealed the following physician orders: - 10/9/2023 contact precautions every shift due to MRSA of the right foot wound. - 11/2/2023 cleanse right foot wound with Dakins (wound cleanser), pat dry, apply a thin layer of Silver Silvadene (antimicrobial wound cream) to the wound bed followed by calcium alginate (wound treatment), and apply a clean dressing and wrap with kling once a day. Multiple surveyor observations from 11/7/2023 through 11/8/2023 revealed that the resident had no signage posted outside his/her room indicating s/he was on contact precautions and did not have an isolation bin containing PPE supplies outside his/her room. Multiple observations on these dates were made of staff entering and exiting the resident's room without wearing the required PPE, which includes gloves and a gown. During an additional surveyor observation on 11/7/2023 at 12:17 PM of RN, Staff A, she was observed completing the above-mentioned treatment to the resident's right foot wound. Staff A completed the wound treatment without having donned a gown. Additionally, the wound was observed to be opened and was noted to have a scant amount of sanguineous (bloody) drainage on the existing dressing. During a surveyor interview immediately following the above observation with Staff A, she revealed Resident ID #14 was not on any isolation precautions. When informed by the surveyor of the active physician order for contact precautions, she revealed only gloves would be required for contact precautions. During a surveyor interview on 11/8/2023 at 3:08 PM with the DNS, she was unaware that Resident ID #14 had an order to be on contact precautions for MRSA in his/her right foot wound. She further revealed that a resident on contact precautions would have signage posted outside the door as well as a bin of PPE. Furthermore, she indicated that after the resident completed his/her antibiotic course, s/he was removed from contact precautions. She was unable to provide evidence that the wound was re-cultured as per policy prior to discontinuing the contact precautions. 3. Review of a facility policy titled Laundry Guidelines dated 10/18 states in part, POLICY: It is the policy of this facility to handle, store, process, and transport linen so as to prevent the spread of infection .Laundry Handling .All laundry will be handled as if it is potentially infectious and/or capable of transmitting infectious disease . According to the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, revised 2/3/2023 states in part, .Handling Laundry .The facility staff should handle all used laundry as potentially contaminated and use standard precautions (e.g., gloves, gowns when sorting and rinsing) . During a surveyor observation on 11/9/2023 at 11:56 AM with the DNS, a walk through of the laundry room was completed. No PPE, e.g gowns, was observed. During a surveyor observation on 11/10/2023 at 8:49 AM with Nursing Assistant, Staff D, she was observed in the laundry room loading the washing machine wearing only gloves. She failed to don a gown when sorting and loading the soiled laundry. When Staff D was asked to show the surveyor how laundry is processed, Staff D proceeded to open the door to the clean side of the laundry room with the same pair of dirty gloves on, she then opened the dryer, removed the lint trap, and then replaced it. She then opened the cleaned stored linen rack still wearing the same pair of dirty gloves and pushed the cleaned linen back in to the storage rack. During a surveyor interview on 11/10/2023 at 11:18 AM with the DNS she was unable to provide evidence that the facility stored, process and transported linen to prevent the spread of infection.