**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, manufacturer's instructions, and facility policy 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 infections. Specifically, the facility failed to: - Ensure multi-use glucometers were cleaned and disinfected after each use by 2 of 3 nurses observed during medication pass, which had the potential to affect 10 residents with orders for blood glucose monitoring. - Ensure proper hand hygiene and glove use when obtaining blood for glucose monitoring by 1 of 3 nurses observed during medication pass. - Ensure staff did not touch medications with their bare hands and use medications that were dropped on an unclean surface by 2 of 3 nurses observed during medication pass - Properly clean and store nebulizer equipment after use for Resident (R)29, which had the potential to affect 5 resident's receiving respiratory therapy - Ensure indwelling urinary catheter drainage tubing was kept off the floor for R18 and R268, which had the potential to affect 6 residents with indwelling catheters. It was determined the facility's noncompliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.80 (Infection Control) at a scope and severity of J. The IJ began on 11/16/22 at 11:46 AM when Registered Nurse (RN)1 failed to clean and disinfect the glucometer between R33 and R269 and was observed putting the dirty glucometer in her pocket when leaving the resident's rooms. The Administrator and Director of Nursing (DON) were notified of the IJ on 11/18/22 at 5:10 PM and provided the IJ Template on 11/18/22 at 5:12 PM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency (SSA) on 11/19/22 at 12:48 PM. The IJ was removed on 11/19/22 at 1:15 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that was not immediate jeopardy for F880. Findings include: 1. A review of the Assure Prism Multi Blood Glucose Monitoring System manual, dated 04/2015, revealed, Before performing a blood glucose test, observe the following safety precautions: All components that come into contact with blood samples should be considered to be biohazards capable of transmitting viral diseases between patients and healthcare professionals. Before testing each patient, a new pair of clean gloves should be worn by the user. Wash hands thoroughly with soap and water before putting on a new pair of gloves and performing the next patient test. Use only an auto-disabling, single-use lancing device for each patient. After use on each patient, the meter should be cleaned and disinfected. The manual also indicated, 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 Assure Prism Multiuser Blood Glucose Monitoring System may only be used for testing multiple patients when standard precautions and the manufacturer's disinfecting procedures are followed. The cleaning procedure is needed to clean dirt, blood, and other bodily fluids off the exterior of the meter before performing the disinfection procedure. The disinfection procedure is needed to prevent the transmission of blood-borne pathogens. A variety of the most commonly used EPA-registered wipes have been tested and approved for cleaning and disinfecting the Assure Prism Multi Blood Glucose Monitoring System. The disinfectant wipes listed below have been shown to be safe for use with this meter: Clorox Germicidal Wipes, Dispatch Hospital Cleaner Disinfectant Towels and Bleach, PDI Super Sani-Cloth Germicidal Disposable Wipe, and CaviWipes1. The manual indicated the following procedure for cleaning and disinfecting, Cleaning Step 1: Wear appropriate protective gear such as disposable gloves. Step 2: Open the towelette container and pull out 1 [one] towelette and close the lid. Step 3: Wipe the entire surface of the meter 3 [three] times horizontally and 3 [three] times vertically using 1 [one] towelette to clean blood and other body fluids. Step 4: Dispose of the used towelette in a trash bin. Disinfecting (The meter should be cleaned prior to disinfection.) Step 5: Open the towelette container and pull out 1 [one] towelette and close the lid. Step 6: Wipe the entire surface of the meter 3 [three] times horizontally and 3 [three] times vertically to remove blood-borne pathogens. Step 7: Dispose of the used towelette in a trash bin. Step 8: Allow exteriors to remain wet for the appropriate contact time and then wipe the meter using a dry cloth. A table of disinfectant brand names and contact times revealed the contact time for CaviWipes1 was two minutes. The manual continued, Step 9: After disinfection, the user's gloves should be removed and thrown away. Wash hands before proceeding to the next patient. Review of a facility policy titled, Handwashing Policy, dated 10/22, specified, It is the policy of [the facility] to reduce potential for spread for unknown pathogens that health care workers may be exposed to when performing daily tasks. Hands will be washed with soap and water or decontaminated using an approved alcohol-based band sanitizer: Before and after each work shift, Before and after contact with each resident, Before dispensing medications, After handling contaminated items, After using the restroom, blowing nose, etc [et cetera], Before and after using PPE [Personal Protective Equipment], Before eating, drinking, and handling food, After contact with inanimate objects in patient care environments. Hands must be washed with soap and water when visibly soiled. During a medication administration observation on 11/16/22 at 11:38 AM, Registered Nurse (RN)1 was observed obtaining a blood glucose level from R33 with a glucometer and then placed the dirty glucometer in her pocket when she walked out of the room. RN1 placed the dirty glucometer in the top drawer of the medication cart. RN1 then removed the glucometer out of the drawer of the medication cart and used it to obtain a blood glucose level from R269 at 11:46 AM. After obtaining the sample, RN1 placed the dirty glucometer in her pocket when she walked out of the room and placed the dirty glucometer in the top drawer of the medication cart. The glucometer machine was not cleaned or disinfected before, after, or in between the residents. During an interview on 11/16/22 at 11:38 AM, RN1 stated the glucometer was cleaned daily with Cavi-1 wipes. During an interview on 11/16/22 at 4:04 PM, Licensed Practical Nurse (LPN)2 stated the glucometer was cleaned daily with sanitizing wipes. An observation on 11/17/22 at 8:47 AM revealed RN2 failed to wash or sanitize her hands or apply gloves before obtaining blood from R268's right middle finger for a blood glucose check. After obtaining the sample, RN2 placed the dirty glucometer in her pocket when leaving the resident's room and placed it in the top drawer of the medication cart without cleaning or disinfecting it. During an interview on 11/17/22 at 11:49 AM, LPN1 stated when obtaining a blood glucose level, she would wash her hands and put gloves on to get the sample. LPN1 stated the glucometer was cleaned carefully with alcohol after every use. During an interview on 11/17/22 at 12:02 PM, RN2 stated the glucometer was cleaned once a day with Cavi-1 wipes. She stated gloves should be worn when obtaining a blood glucose level. During an interview on 11/17/22 at 12:16 PM, RN1 stated the gloves should be worn when obtaining blood glucose levels and giving insulin and the glucometer was cleaned every shift with the Cavi-1 wipes. During an interview on 11/17/22 at 2:44 PM, the Assistant Director of Nursing (ADON) stated when the nurse was checking a resident's blood sugar, they should wash their hands and wear gloves. The ADON stated the glucometer should be cleaned after each use but was unsure how it was cleaned. During an interview on 11/18/22 at 11:10 AM, the Director of Nursing (DON) stated when the nurse was obtaining a blood glucose level, they should wash their hands and wear gloves. The DON stated the glucometer should be cleaned before and after each use with Cavi-1 wipes and the nurse should not be putting the glucometer in their pockets. During an interview on 11/19/22 at 11:50 AM, the Administrator stated he expected the nurses to follow manufacturers recommendations and the facility's policy for cleaning of the glucometer. He stated he expected the staff to wash their hands or sanitize and use gloves, as per their policy. 2. Observations on 11/16/22 at 11:51 AM revealed Registered Nurse (RN)1 prepping and administering medications for R3. She was attempting to pour a pill out of a bottle of iron pills into a plastic medication cup and poured out too many. RN1 reached into the medication cup with her bare fingers and pulled out the extra pill and placed it back into the medication bottle. Observations on 11/17/22 at 9:02 AM revealed RN2 prepping and administering medications for R21. RN2 accidentally dropped three pills out of the prepackaged pills from the pharmacy onto the top of the medication cart. RN2 picked up the pills with her bare fingers and placed the pills in the plastic medication cup and administered them to the resident. During an interview on 11/17/22 at 11:49 AM, Licensed Practical Nurse (LPN)1 stated if the nurse dropped pills onto the medication cart, they should have been thrown away. She stated medications should not be touched with bare hands. During an interview on 11/17/22 at 12:02 PM, RN2 stated general nursing would tell her that if medications were dropped or needed to be removed from a medication cup, they probably should not be used. She stated she would have to look up the facility's policy on that. During an interview on 11/17/22 at 2:44 PM, the Assistant Director of Nursing (ADON) stated medications that have been dropped on top of the medication cart should be discarded and medications should not be touched with bare hands when removing from the cup. During an interview on 11/18/22 at 11:10 AM, the Director of Nursing (DON) stated pills should not be touched with bare hands and the pills that were dropped should have been discarded. During an interview on 11/19/22 at 11:50 AM, the Administrator stated the nurse should not be touching pills with their bare fingers and the medications that were dropped should have been discarded. 3. Review of a facility policy titled, Oxygen/Respiratory Therapy, dated 03/2019, specified, Nebulizer sets will be changed weekly. Tubing not in use, when orders are PRN [as needed] or at specific times of the day will be stored in a plastic bag. A review of an admission Record indicated the facility admitted R29 with diagnoses that included chronic respiratory failure with hypoxia (a deficiency in the amount of oxygen reaching the tissues) and chronic obstructive pulmonary disease (COPD). The quarterly Minimum Data Set (MDS), dated [DATE], revealed R29 had a Brief Interview for Mental Status (BIMS, a structured evaluation for cognition) score of 6, which indicated the resident had severe cognitive impairment. The resident required extensive to total assistance with all activities of daily living (ADLs). The resident was receiving oxygen therapy while at the facility. Review of R29's care plan, with a target goal date of 12/20/22, revealed interventions related to the resident's altered respiratory status directed staff to assess the resident's respiratory status, assess breath sounds, position to facilitate breathing and comfort, suction as needed (PRN), administer oxygen as ordered, and assist with respiratory devices as ordered. A review of R29's Order Summary Report revealed orders included: - Change oxygen tubing every week on day shift every Friday, ordered 06/02/22. - Oxygen at 2-5 liters per minute via nasal cannula to maintain pulse ox above 92% as needed if the resident had signs and symptoms or complaints of shortness of breath, ordered 06/02/22. - Ipratropium-Albuterol Solution 0.5-2.5 (3) milligrams (mg)/3 milliliters (mL), inhale 3 ml orally three times a day for nebulization therapy, ordered 06/02/22. There were no orders to change the nebulizer equipment. Observations on 11/14/22 at 2:34 PM revealed R29's nebulizer machine on the mattress at the head of Resident #29's bed with the tubing and mask connected and hanging on the handle on the side of the over the bed table. Observations on 11/15/22 at 12:34 PM revealed R29's nebulizer machine on the over the bed table with the tubing and mask lying on the table next to the machine. Dried debris was seen on the mask. The mask had not been rinsed out or stored. Observations on 11/16/22 at 10:01 AM revealed R29's nebulizer machine was on the over the bed table with a partially full urinal next to it with the mask hanging on the handle on the side of the table. Dried debris was seen on the mask. The oxygen tubing and humidifier bottle on the concentrator were not dated. During an interview on 11/17/22 at 11:49 AM, Licensed Practical Nurse (LPN)1 stated the nebulizer mask or canister should be cleaned, rinsed out, and stored in a bag after every time it was used. She stated the tubing was changed every three days with the date put on the tubing. During an interview on 11/17/22 at 12:02 PM, Registered Nurse (RN)2 stated nebulizer equipment should be rinsed with hot water, dried, and put in a bag. She stated she did not know how often the oxygen tubing or nebulizer equipment was supposed to be changed and would have to look at the policy. During an interview on 11/17/22 at 12:16 PM, RN1 stated after a resident completed a nebulizer treatment, the equipment should be wiped down and the tubing should be wrapped up and put on the machine. She stated the oxygen and nebulizer tubing was changed weekly. During an interview on 11/17/22 at 2:44 PM, the Assistant Director of Nursing (ADON) stated after a resident completed a nebulizer treatment, the nurse should wipe down the equipment, rinse it out and let it air dry then store it in a plastic bag at the bedside. She stated she was unsure of the policy on how often the oxygen tubing and nebulizer equipment was to be changed. During an interview on 11/18/22 at 11:10 AM, the Director of Nursing (DON) stated nebulizer equipment, the mask, tubing, and canister, needed to be cleaned and stored appropriately. She stated the bag the equipment was stored in, and the equipment should be changed once a week and dated. During an interview on 11/19/22 at 11:50 AM, the Administrator stated he expected the nurses to follow manufactures recommendations and the facility policy for cleaning nebulizers. 4. Review of an undated facility policy titled, Catheter Care Policy, indicated the policy did not reveal any guidance on managing the catheter bag or the catheter tubing when in use by the resident. A review of an admission Record indicated the facility admitted R18 with diagnoses that included Alzheimer's disease, lupus, adult failure to thrive, sacral pressure ulcer, and diverticulum of bladder. The quarterly Minimum Data Set (MDS), dated [DATE], revealed R18 had a Brief Interview for Mental Status (BIMS, a structured evaluation for cognition) score of 15, which indicated the resident was cognitively intact. R18 required extensive assistance with bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. The resident had an indwelling catheter. A review of R18's care plan, initiated 02/03/22, revealed interventions related to the resident's indwelling urinary catheter directed staff to provide catheter care per policy and to keep the catheter bag covered and below the level of the bladder. There were no interventions to keep the catheter bag or drainage tubing off the floor. On 11/15/22 at 11:43 AM, R18 was observed self-propelling a wheelchair in the hallway. The resident's urinary catheter bag was observed filled with urine, hanging from the bottom of the wheelchair. The drainage tubing was dragging on the floor beneath the resident's feet. On 11/15/22 at 2:33 PM, R18 was observed riding a recumbent bike in the therapy gym. The urinary catheter bag was observed hanging on the wheelchair positioned beside the resident. The drainage tubing, attached to the catheter bag, was on the floor. On 11/16/22 at 9:08 AM, R18 was observed seated in the wheelchair in their room. The drainage tubing attached to the urinary catheter bag was on the floor beneath the wheelchair. During an interview on 11/17/22 at 9:18 AM, Certified Nursing Assistant (CNA)2 stated the catheter tubing had to be straight and without kinks. The CNA indicated there were no other instructions related to the management of the drainage tubing or the catheter bags. During an interview on 11/17/22 at 9:45 AM, Registered Nurse (RN)1 stated the drainage tubing and the catheter bag should never be on the floor. During an interview on 11/17/22 at 9:55 AM, CNA3 stated the catheter bag and drainage tubing should not touch the floor. The CNA stated, It's not sanitary. During an interview on 11/17/22 at 10:06 AM, RN2 stated the drainage tubing and catheter bag should not be on the floor. RN2 further stated she would refer to the facility policy for clarification. During an interview on 11/17/22 at 10:22 AM, CNA4 stated the catheter bags and drainage tubing should never be on the floor. During an interview on 11/18/22 at 9:14 AM, the Director of Nursing stated the catheter bag and drainage tubing should never touch the floor. It was her expectation that if a staff member observed the catheter bag/tubing to be on the floor they would intervene. During an interview on 11/19/22 at 11:51 AM, the Administrator stated it was his expectation that catheter bags and drainage tubing were never on the floor. 5. A review of an admission Record indicated the facility admitted R268 with diagnoses that included chronic kidney disease, benign prostatic hyperplasia with lower urinary tract symptoms, and retention of urine. R268 did not have a completed Minimum Data Set (MDS) assessment, as the resident was newly admitted . A review of R18's care plan, initiated 11/11/22, revealed interventions related to the resident's indwelling urinary catheter directed staff to provide catheter care per policy and keep the catheter bag covered and below the level of the bladder. There were no interventions to keep the catheter bag or drainage tubing off the floor. On 11/14/22 at 12:08 PM, R268 was observed in their room lying in the bed. The urinary catheter bag and drainage tubing were lying on the floor. On 11/14/22 at 2:13 PM, R268 was observed seated on the side of the bed. The urinary catheter drainage bag was hung on the side of the bed rail, and the tubing was on the floor by the resident's feet. During an interview on 11/17/22 at 9:18 AM, CNA2 stated the catheter tubing had to be straight and without kinks. The CNA indicated there were no other instructions related to the management of the drainage tubing or the catheter bags. During an interview on 11/17/22 at 9:45 AM, RN1 stated the drainage tubing and the catheter bag should never be on the floor. During an interview on 11/17/22 at 9:55 AM, CNA3 stated the catheter bag and drainage tubing should not touch the floor. The CNA stated, It's not sanitary. During an interview on 11/17/22 at 10:06 AM, RN2 stated the drainage tubing and catheter bag should not be on the floor. RN #2 further stated she would refer to the facility policy for clarification. During an interview on 11/17/22 at 10:22 AM, CNA4 stated the catheter bags and drainage tubing should never be on the floor. During an interview on 11/18/22 at 9:14 AM, the Director of Nursing stated the catheter bag and drainage tubing should never touch the floor. It was her expectation that if a staff member observed the catheter bag/tubing to be on the floor they would intervene. During an interview on 11/19/22 at 11:51 AM, the Administrator stated it was his expectation that catheter bags and drainage tubing were never on the floor. Removal Plan: The Removal Plan regarding not cleaning or disinfecting the glucometer between residents was accepted by the State Survey Agency (SSA) on 11/19/22 at 12:48 PM. The Removal Plan included, 1. Immediately on 11/18/22 at 5:45 PM all glucometers were cleaned and disinfected according to manufacturer's instruction by the Director of Nursing; this process involved Cleaning: 1. Donning Gloves, 2. Opening the towelette container and pulling out one towelette and closing the lid, 3. wiping the entire surface of the meter 3 times horizontally and three times vertically, 4. disposing of the used towelette in a trash bin) and disinfecting the meter, which included: 1. Opening the towelette container and pulling out one towelette and closing the lid, 2. wiping the entire surface of the meter 3 times horizontally and three times vertically, 3. Disposing of the used towelette in a trash bin, 4. Allow exteriors to remain wet for the appropriate amount of time and then wipe the meter using a dry cloth, 5. removing of and discarding gloves) 2. Immediately on 11/18/22 at 5:56 PM the physician of R33, R269, and R268, and 7 other residents with orders for blood glucose monitoring were notified by the facility Director of Nursing of the alleged deficient practice. The Director of Nursing made the Medical Director aware of the allegation on 11/18/22. R33, R269, and R268, and other residents receiving blood glucose monitoring and their responsible parties were notified by the Director of Nursing or designee on 11/18/22. 3. In-services: On 11/18/22 prior to 7:30 PM, all licensed nursing staff were educated on the proper cleaning for glucometers, blood borne pathogen transmission, infection control, glove wearing and hand washing. On 11/18/22 at 7:15 PM education and return demonstration was successfully completed for licensed nurses on the scheduled day and night shift of 11/18/22. Education was provided by the Director of Nursing to each Licensed Nurse. All Licensed Nurses not immediately available in the facility at this time, were educated via phone and will be expected to sign the in-service sheet and complete return demonstration in-person at the start of their next scheduled shift or on the next business day, whichever comes first, by the Director of Nursing or RN Designee. Licensed Nurses were educated to always follow manufacture's guidelines for glucometer cleaning and disinfection as provided by manufacturer of Assure Prism Glucometer; this includes the process of cleaning (1. Donning Gloves, 2. Opening the towelette container and pulling out one towelette and closing the lid, 3. Wiping the entire surface of the meter 3 times horizontally and three times vertically, 4. disposing of the used towelette in a trash bin) and disinfecting the meter (1. Opening the towelette container and pulling out one towelette and closing the lid, 2. wiping the entire surface of the meter 3 times horizontally and three times vertically,3. Disposing of the used towelette in a trash bin, 4. Allow exteriors to remain wet for the appropriate amount of time and then wipe the meter using a dry cloth, 5. removing of and discard gloves). This process was demonstrated by the Director of Nursing and was repeated by each nurse during education. 4. On 11/18/22 prior to 7:30 PM, The director of Nursing educated all Licensed Nurses on the policy for Handwashing and Blood Glucose Testing. 5. Audits will be conducted by the Director of Nursing and/or Designee by observation of blood glucose monitoring by licensed nurses on 4 to 5 residents a week for four weeks, and then randomly thereafter for a total of four months to ensure compliance with cleaning and disinfection of glucometers. Results of audits will be reviewed by the QAPI [Quality Assurance and Performance Improvement] committee monthly to ensure compliance for four months. All corrections were completed on [11/18/22]. The immediacy of the IJ was removed on [11/19/22]. Onsite Verification of Removal Plan: The IJ was removed on 11/19/22 at 1:15 PM after the survey team conducted an onsite verification that the Removal Plan had been implemented. The survey team verified the facility identified 10 residents that could be affected by the deficient practice and verified each resident, the resident's primary care physician, and responsible parties were notified of the potential infection control breach and allegation. The education the facility provided to the nurses was reviewed and included the manufacturer's directions for cleaning and disinfecting the glucometers, the facility's policy on blood glucose testing protocol and handwashing, and Relias training on standard precautions and bloodborne pathogens. A review of the in-service sign in sheet compared with the facility's list of nursing staff revealed all nursing staff had been educated on cleaning and use of the glucometer, handwashing, and glove use either in person or by phone. This was verified with interviews with three nurses onsite at the facility and two nurses by phone. Return demonstration was completed with all nurses at the facility by the DON, and this was confirmed with interviews. The DON stated all nurses would perform a return demonstration prior to working the floor.