Inadequate Infection Control and Water Management in LTC Facility
Penalty
Summary
The facility failed to conduct comprehensive infection surveillance for resident infections, as evidenced by the Director of Nursing (V2) not completing McGeer's Criteria assessments for residents with infections. Instead, V2 relied on a monthly list of residents who received antibiotics to track infection trends, which did not provide accurate surveillance. The Order Listing Reports for January, February, and March 2025 showed that anti-infectives were prescribed, but no surveillance was completed. This lack of comprehensive infection surveillance was acknowledged by the facility's Administrator (V1), who stated that V2 should have been conducting surveillance for all infections identified in the facility. The facility also failed to maintain a complete water management program for Legionella. The Maintenance Director (V23) admitted to not documenting water temperatures of hot water heaters or tanks, not performing chlorine testing, and not maintaining documentation of running water in vacant resident rooms. V23 was unaware of the control measures for the facility's water management plan for Legionella and did not know how to respond if control measures were not met. The facility lacked documentation to show a water management plan containing areas at risk for Legionella growth, control measures, or routine safety logs for control measures. Additionally, the facility failed to adhere to Enhanced Barrier Precautions (EBP) and hand hygiene policies. An LPN (V28) did not wear the required PPE gown while administering medications and flushing a gastric tube for a resident on EBP status. V28 also failed to perform hand hygiene before and after glove use during medication administration and insulin injection procedures. Another resident (R29) with multiple infections did not have appropriate contact precautions signage outside their room, and a wound nurse (V12) was unaware of a resident's order for EBP, failing to use PPE while examining the resident's wound. These actions were not in compliance with the facility's policies on EBP, hand hygiene, and infection precautions.