Widespread Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to implement and document its Water Management Plan for Legionella as required by its own policies. The Maintenance Director did not monitor or document water temperatures in accordance with the plan, only checking a limited number of locations and failing to log hot water tank temperatures. There was no documentation of control measures or monitoring activities prior to a specific date, and the required weekly flushing and cleaning of eye wash stations was not performed as outlined in the facility's risk assessment and water management guidelines. Laundry staff did not adhere to the facility's linen handling policy, as soiled laundry was handled without the use of required personal protective equipment such as aprons or gowns. The staff member responsible for laundry confirmed that only gloves were used, and no aprons or gowns were available in the laundry room, contrary to policy requirements for handling potentially contaminated linens. Multiple infection control breaches were observed during resident care and medication administration. A resident on contact isolation for ESBL in urine was allowed to participate in group activities and therapy without appropriate precautions, and therapy staff were unaware of the resident's isolation status. Hand hygiene was not performed by staff between glove changes or after providing care, and medical devices such as blood pressure monitors were not disinfected between uses on different residents. These lapses occurred despite facility policies requiring hand hygiene and equipment disinfection between resident contacts.