Failure to Implement Infection Control Measures and Proper Labeling
Penalty
Summary
The facility failed to implement proper infection prevention and control practices in several key areas. After a positive water test for Legionella was performed, the results and recommended actions were not communicated to the nursing department, administration, or infection prevention staff. The Director of Facility Management was aware of the positive test but did not notify the appropriate parties, and no action plan was initiated to remediate the affected water sources. As a result, residents, including those with tracheostomies, were exposed to Legionella-contaminated water for over two months without any corrective measures being taken. Additionally, an open enteral feeding system for a resident was not labeled with the correct date and time. The feeding bag at the resident's bedside was marked with an incorrect date, and there was no indication of the time it was prepared or the nurse's initials. The nurse confirmed the labeling was incorrect and acknowledged that the system should be changed every 24 hours, as per facility policy, to prevent bacterial growth and infection. Furthermore, sterile respiratory water, a tracheostomy mask, and a nebulizer used for the same resident were not labeled with the date and time they were last changed. The respiratory therapist could not determine when these items had last been replaced, and the infection prevention nurse confirmed that these items should be labeled and changed according to the facility's policy. The lack of proper labeling and adherence to change schedules for respiratory equipment and enteral feeding systems increased the risk of infection for residents with compromised health conditions.