Infection Control Deficiencies in Vaccination, Water Management, and Equipment Sanitization
Penalty
Summary
The facility failed to maintain proper infection control prevention practices, as evidenced by three specific deficiencies. Firstly, the facility did not provide documentation of pneumococcal vaccination screening, administration, or declination for two staff members, a Certified Nurse Aide and a Laundry Aide. The Licensed Practical Nurse responsible for collecting immunization data admitted to not having completed forms for these staff members, indicating a lapse in ensuring that employees were educated and had the opportunity to consent to or decline the vaccine. The Director of Nursing acknowledged the oversight and attributed it to the delegation of vaccine tasks to the Licensed Practical Nurse. Secondly, the facility's Water Management Plan, crucial for preventing and controlling Legionella, was found to be undated with no evidence of annual review or updates. The Director of Maintenance was unaware of the oversight. Lastly, during a medication pass observation, an LPN was seen placing an unsanitized blood pressure cuff back into the medication cart after use, contrary to the facility's policy requiring sanitization between uses. The Director of Nursing confirmed that shared equipment should be sanitized with alcohol or sanitizing wipes after each use.
Plan Of Correction
Plan of Correction: Approved April 11, 2025 Element #1: The following actions were accomplished for the resident(s) identified in the deficient practice: - Nurse Aide #15 and laundry aide #16 were offered the pneumococcal vaccine on 3/12/25; both declined and signed a declination form. - Education provided to LPN #17 on the requirements for all employees to have documented immunization status; including eligibility, education and administration of vaccines and that signed consents/declinations are maintained on file. - The water management plan was reviewed and updated on 3/5/2025 and verbal education was provided to the Maintenance Director on the documentation requirements for the water management plan which includes, at minimum, an annual documented review of the water management plan. - Licensed practical nurse #18 was educated on the requirement to sanitize blood pressure cuffs after use, prior to being placed in the medication cart. Element #2: The following actions will be implemented to identify other residents who have the potential to be impacted by the deficient practice: - All Residents have the potential to be affected; however, no residents have been negatively impacted. - Staff Educator/designee completed an audit of all employee vaccination status, and the pneumococcal vaccine will be offered to any employee identified as needing such based off of audit findings. Element #3: The following system changes will be implemented to prevent reoccurrence: - The facility policy and procedure titled “Pneumococcal Vaccination Program for Employees” was reviewed and found to be appropriate. - The staff educator/designee will provide education to all employees upon hire and at least annually on the pneumococcal vaccine and will obtain a signed consent or declination for the vaccine. Consent/declination forms will be retained on file. - The staff educator/designee will provide education to all licensed nurses on the requirement to properly sanitize blood pressure cuffs after use and prior to placing in medication cart for storage. - The administrator provided verbal education to the Maintenance Director on 3/5/2025 on the requirement to complete and update the water management plan on an annual basis. Element #4: The facility’s compliance with the corrective action will be monitored using the following quality assurance system: - The Director of Nursing has created an audit tool to ensure that all employees were offered the pneumococcal vaccine upon hire and annually and that a consent/declination form is signed by the employee. - The Director of Nursing has created an audit tool to ensure that licensed staff are properly sanitizing blood pressure cuffs after use. - ADON/Designee will complete a full house audit of employee vaccination records monthly until 100% compliance is attained for 3 consecutive months. Negative findings will be corrected and reported to the Director of Nursing. - Unit managers/designee will audit once a week to ensure that blood pressure cuffs are properly sanitized in between residents until 100% compliance is attained for 4 consecutive weeks. Negative findings will be corrected and reported to the Director of Nursing. - Results of audits will be reviewed during monthly QAPI meetings and the QAPI committee will determine ongoing audit frequency for blood pressure cuffs after 4 weeks of 100% compliance; and for employee vaccinations after 3 months of 100% compliance. Element #5: The person responsible for the corrective actions is the Director of Nursing/designee. Date of compliance is 4/18/25.