Smp Health - St Raphael

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 2 of 7 sampled residents (Resident #16 and #73) observed during cares.

Failure to remove gloves and perform hand hygiene during wound care and perineal care has the potential to spread infection throughout the facility.

Findings include: Review of the facility policy titled Glove Usage occurred on 09/24/25.

This policy, revised November 2018, stated, Purpose: To reduce the risk of exposure, prevent the spread of infection, identify situations where usage of gloves is appropriate and incorporating proper usage of gloves.

Procedure: . 2.

Once gloves are contaminated, they must be changed before touching clean items or proceeding to perform clean procedure. 7.

Hand hygiene must be performed prior to gloving and after removing gloves.

Review of the facility policy titled Hand Hygiene occurred on 09/24/25.

This policy, revised September 2023, stated, Purpose: .

Hand hygiene . an effective method for preventing the spread of pathogens, such as bacteria and viruses, which cause infections.

Condition: Hands are visibly soiled with blood or other body fluids.

After handling contaminated objects.

Before and after handling clean or soiled dressing. -Observation on 09/23/25 at 9:39 a.m. showed the nurse (#1) performed a dressing change for Resident #73.

The nurse applied personal protective equipment (PPE), a gown and gloves and entered the resident's room.

The nurse removed a soiled abdominal (ABD) pad from the left hip of Resident #73.

Without removing her gloves, the nurse (#1) cleaned the area with wound cleanser, placed a new ABD, and applied tape.

The nurse (#1) then removed the gown and gloves and washed her hands.

The nurse failed to remove gloves, perform hand hygiene, and apply new gloves prior to applying the clean dressing. -Observation on the afternoon of 9/23/2025 showed two certified nurse aides (CNAs #2 and #5) applied gowns and gloves and transferred Resident #16 from the wheelchair to the bed using the mechanical lift.

The CNA (#2) wore gloves and completed Resident #16's perineal care after a soft bowel movement.

With the same gloves, the CNA reached into a container of ointment and applied it to the resident's bottom, fastened the new brief, pulled up his pants, opened up a drawer to retrieve a bandana and placed it by the resident's mouth.

The CNA (#2) removed her gown, and with same gloves still on plugged in a pump, tied a garbage bag, lowered the bed, turned the television on, took the pillowcase off the resident's neck pillow, tied a garbage bag, and then removed gloves and performed hand hygiene.

The CNA (#2) failed to remove gloves and perform hand hygiene after perineal care and prior to doing other tasks in the resident's room.

During an interview on the afternoon of 09/24/25, an administrative nurse (#4), confirmed staff should remove gloves and performed hand hygiene after removing a soiled dressing and after performing perineal cares.

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