Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as required by federal regulations. The Infection Preventionist did not track or monitor employee illnesses, which limited the facility's ability to identify and respond to outbreaks, as evidenced by the lack of data on employee sick calls during a COVID outbreak. Infection control policies, including those for influenza and pneumococcal vaccinations, were outdated, with some not reviewed or revised for several years. The facility's infection surveillance policy required tracking of staff infections, but this was not being implemented. Additionally, the facility's infection control policies were not updated annually as required. Direct care observations revealed multiple failures in hand hygiene and infection control practices. During wound care for three residents, staff did not clean bedside tables or use barriers for supplies, did not change gloves or perform hand hygiene between dirty and clean tasks, and used the same gloves for wound care and peri care. Supplies and equipment, such as wound care scissors, were not properly cleaned or were returned to common carts after being contaminated. Staff interviews indicated a lack of understanding of proper hand hygiene protocols, with some staff and the DON stating that gloves only needed to be changed if visibly soiled, and that urine was not considered a contaminant requiring glove changes. These practices were inconsistent with both facility policy and CDC guidelines. Additional deficiencies were identified in the handling of medications and water management. A urine sample was found stored in a medication refrigerator, contrary to policy requiring separation of potentially harmful substances from medications. The facility also lacked an active and ongoing water management plan to reduce the risk of Legionella and other waterborne pathogens. The Maintenance Director was unaware of key aspects of the water management program, including team membership, control limits for chlorine, and the requirement for annual review and team meetings. The facility's water management policy called for an interdisciplinary team and regular reviews, but these were not being conducted.
Plan Of Correction
1. Resident #1, #4, and #25 continue to reside at the facility and no negative outcomes were identified related to the deficient practice. DPS B A digital testing unit was purchased, and levels remain at acceptable levels as of 4/25/2025. 2. All residents may be impacted by this deficient practice. The facility completed an infection screening evaluation on all residents as of 4/30/2025. Any resident identified with an additional wound or signs/symptoms of an infection will be treated accordingly, and their care plans will be updated. Current residents can be impacted by Legionella. Water levels will continue to be monitored as required. 3. The facility has reviewed the facility Infection Control Plan; this policy is deemed appropriate. The facility's Regional Nurse Consultant educated the DON on proper infection control policies, including hand hygiene. Clinical staff were provided with education on the Infection Control Plan by the DON/designee after the DON educated them, including proper hand hygiene, maintaining a clean work environment, and employee illness management. The ICP has been appropriately educated on infection tracking and trending. 4. The facility has incorporated the Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings. The Water Management Plan has been updated using the CDC Toolkit, including establishing core members. The Director of Plant Operations educated the members of the WMP on understanding what Legionella is and understanding the facility's water system by 4/30/2025. 5. The QAPI Committee has directed the DON/Designee to perform random weekly audits of proper infection control procedures and tracking and trending. The Committee has also directed the Director of Plant Operations to perform weekly tests for Legionella. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.