Infection Control Deficiencies in Water Management and PPE Use
Penalty
Summary
The facility failed to maintain infection control prevention practices, as evidenced by the absence of a documented environmental risk assessment and water management plan to prevent and control Legionella and other waterborne pathogens. The Director of Facilities and Lead Engineer were unaware of who was responsible for completing these assessments, and no updates had been made from November 2023 to January 2025. This lack of documentation and clarity in responsibility indicates a significant oversight in the facility's infection prevention and control program. Additionally, an environmental service worker entered a contact isolation room without donning personal protective equipment or performing hand hygiene, despite the resident being on contact precautions for Clostridium difficile. The worker admitted to not paying attention to the precautionary signage and acknowledged the need for proper infection control measures. The Director of Nursing and the Infection Preventionist confirmed that all staff are required to follow these protocols, highlighting a lapse in adherence to established infection control guidelines.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice is: Immediate training was provided to all Environmental staff worker on 1/30/25. Immediate education was given to New Director of Plant Operations on The New Jewish Home Water Management Plan and Environmental Risk assessment and where all documents of such are kept. Administrator will meet monthly with New Director to review and ensure that necessary documentation is in place and new director is properly educated on all testing that is mandated for The New Jewish Home (NAME) Neuman. 2. How will The New Jewish Home (NAME) Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above)? All residents have the risk to be potentially affected by this deficient practice. The New Jewish Home will continue to properly follow the Water management plan that was in place at time of Survey, but new Director failed to produce the information at the time he was asked. Water Management plan and records of legionella testing between dates of 11/23 and 1/25 were available in the facility at time of survey. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur? Training will be provided on date of hire and bi-annually for all environmental service workers in regards to the Infection Control Policy. Training will be conducted by ADON Infection Control and/or designee. The Director of Environmental Services and/or designee is responsible for scheduling the training sessions. The New Jewish Home will continue to comply with Water Management plan and Evaluation for Legionella, following regular testing and evaluation as plan states. The Administrator will educate Plant Operation leadership and Nursing Infection Control Manager to have a full understanding of the legionella policy, water management plan and ongoing testing. 4. How will The New Jewish Home (NAME) Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e. - what program will monitor the continued effectiveness of the systemic change)? The Director of Environmental Services and/or designee will be provided with a tool for rounding to ensure compliance with the Infection Control Policy. The completed audit tool will be submitted to the Infection Control Preventionist after the rounding. A verbal report of those employees requiring remediation will be communicated at the time the audit is submitted. The Director of Environmental Services and/or designee will conduct weekly audits for one month. Results of audits will be submitted to the Infection Preventionist and results of the audit will be reported to the QAPI committee monthly by the Infection Preventionist for 3 months to the QAPI committee for action as appropriate. Water Management plan review and reporting will be added to the facility QAPI meeting agenda quarterly.