Deficiencies in Infection Control and Water Management
Penalty
Summary
The facility was found to have deficiencies in its infection prevention and control program, specifically related to the management of water systems and hand hygiene practices. During a tour, it was observed that the facility lacked an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens in its plumbing system. Maintenance staff were unaware of regular flushing procedures for unused water fixtures, and brown, discolored water was observed in several areas, indicating a lack of routine flushing. Additionally, the facility did not have an active team overseeing the water management plan, and there was uncertainty about the permitting of the secondary treatment system. Infection control practices were also found to be lacking during resident care. For instance, a CNA was observed providing incontinence care to a severely cognitively impaired resident without changing gloves or performing hand hygiene between dirty and clean tasks. Similarly, an RN and an LPN failed to use proper PPE during G-tube medication administration and dressing changes for residents under enhanced barrier precautions. The RN did not change gloves or perform hand hygiene while handling various items and performing tasks, and the LPN did not wear a gown during medication administration, contrary to facility policy. The facility's infection control policy requires enhanced barrier precautions, including gown and glove use, during high-contact care activities. However, staff interviews revealed a lack of understanding and adherence to these precautions. The Director of Nursing and the Staff Educator/Infection Preventionist acknowledged the need for proper PPE use and hand hygiene but noted that glove use during incontinence care was not frequently audited. These deficiencies highlight significant lapses in infection control practices, increasing the potential for cross-contamination and disease transmission among residents.
Plan Of Correction
DSP A Element #1 No residents identified. Element #2 Residents residing in the facility have the potential to be affected. Front and Back 200 Spa rooms have been flushed to include tubs and commodes. Front and Back 100 soiled utility rooms have been flushed to include hopper sprayers. Element #3 Maintenance Technician and EVS supervisor have been re-educated on facility Water Safety and Management plan to include routine flushing and commissioning of portable water systems and Wednesday Water flushing protocols. Element #4 EVS/Designee to complete random weekly audit of required Wednesday flushing to include Spa and soiled utility areas. Variances will be addressed at the time of observation. Weekly audits to be submitted to the facility QAPI committee for review and further recommendations. Element #5 The Administrator is responsible for compliance. F880 DSP B Element #1 Residents #1, #29, #52, and #65, have had no adverse outcomes related to observations. Element #2 Residents residing in the facility have potential to be affected. Element #3 Licensed nursing staff have been reeducated on Infection Prevention and Control policy, including hand hygiene, peri care, enhanced barrier precautions, and g-tube care. Infection Control and prevention policy has been reviewed by DON and Administrator and deemed appropriate. All staff were re-educated on hand hygiene and enhanced barrier precautions. Element #4 Don/Designee will complete random weekly audits to ensure appropriate PPE, infection control practices including EBP, hand hygiene, peri care/catheter care, and g-tube care are followed. Variances will be addressed at the time of observation. Weekly audits to be submitted to the facility QAPI committee for review and further recommendations. ELEMENT #5 The Administrator is responsible for sustained compliance.