Failure to Implement Infection Control Measures for Water Testing and Visitor PPE
Penalty
Summary
The facility failed to implement required infection control measures in two key areas. First, the facility did not conduct annual Legionella water testing as outlined in its own policies and procedures. Review of the Water Management Program Binder revealed no Legionella testing results for 2024, and the Infection Preventionist Nurse (IPN) was unsure about the annual testing requirement. The contracted testing company confirmed that a scheduled test was canceled by the previous administrator, and the Maintenance Supervisor stated that a risk assessment was performed instead, which he believed could not replace actual Legionella testing. The facility's policies specifically required annual CDC elite Legionella testing, and staff interviews confirmed that this was not completed as required. Second, the facility failed to ensure that visitors of a resident on Enhanced Barrier Precautions (EBP) wore appropriate personal protective equipment (PPE) during their visit. The resident in question had multiple diagnoses, including hemiplegia, hemiparesis, urinary tract infection, dysphagia, diabetes, hypertension, and severe sepsis, and was dependent on staff for daily activities. Observations showed that four visitors were in the resident's room without PPE, engaging in direct contact such as holding hands, hugging, and sitting on the resident's bed. Although the family member was aware of EBP and the location of PPE, staff did not enforce the use of PPE during the visit. Facility policies required staff to educate and remind visitors about EBP and PPE use, but this was not consistently implemented. Staff interviews confirmed the importance of enforcing EBP to prevent the transmission of pathogens, and the Infection Preventionist acknowledged that all staff were responsible for visitor education regarding infection control measures. The failure to follow these protocols resulted in compromised infection control practices within the facility.