Deficiency in Infection Control and Water Management
Penalty
Summary
The facility failed to maintain a comprehensive infection prevention and control program, specifically in managing the risk of Legionella bacteria in its water systems. The facility's policy on 'Legionella Prevention' was found lacking as it did not include measures to prevent microbial growth throughout the facility. The facility did not implement control measures for Legionella for eleven out of twelve months, from February 2024 through January 2025. The facility's water management plan was incomplete, missing specific testing protocols, acceptable ranges for control measures, and a description of the water system using a flow diagram. Additionally, there was no log for monitoring chlorine concentration levels in the water, which are crucial for controlling Legionella growth. The report also identified a failure to implement transmission-based precautions for a resident diagnosed with shingles. The resident, who had been admitted to the facility with conditions including anemia, Alzheimer's Disease, hyperlipidemia, and multiple pressure ulcers, was not placed in the necessary contact precautions for shingles. The facility's records lacked documentation of Enhanced Barrier Precautions (EBP) for the resident's wounds and indwelling medical devices, which are critical for preventing the spread of infections. Interviews with facility staff revealed a lack of clarity and communication regarding the implementation of isolation precautions. The Infection Preventionist confirmed that there was no documentation in the resident's care plan to reflect the necessary precautions for shingles, nor were EBPs implemented for the resident's wounds and medical devices. This oversight indicates a significant gap in the facility's infection control practices, as required by regulatory standards.
Plan Of Correction
Water lines were tested on January 29, 2025. Chlorine was at appropriate levels. Facility maintenance will enact a monthly water test on water lines to ensure correct levels of chlorine are present. The water management manual was updated to include water testing. All maintenance staff will be educated on the process and testing by the Director of Maintenance or designee. The Director of Maintenance or designee will perform monthly testing to ensure proper levels of chlorine are present in the water supply lines. A QAPI will be started and verified by the Director of Maintenance or designee; all results will be reported to the QA committee. Resident R36's plan of care was updated to reflect the enhanced barrier precautions that were in place for the resident, and a physician order was obtained for Enhanced Barrier Precautions. All resident care plans and physician orders were checked to ensure that enhanced barrier precautions were present where necessary. Education was provided by the Director of Nursing on updating the care plan and physician orders when enhanced barrier precautions are put into place. The Director of Nursing or designee will complete an audit to ensure care plans and orders are updated with enhanced barrier precautions, weekly for one month, bi-weekly for one month, and monthly thereafter. All results will be reported to the QA committee.