Infection Control Failures in PPE Use, Water Management, and Linen Handling
Penalty
Summary
The facility failed to properly implement its infection prevention and control program in several areas. For one resident with dementia and muscle weakness, who was under contact precautions due to a suspected MRSA infection in a heel wound, staff did not follow required protocols. Despite clear signage on the resident's door instructing staff to don gloves and a gown before entry, a certified nursing assistant entered the room without the appropriate personal protective equipment. The infection preventionist confirmed that the resident's status had recently changed to contact precautions and that gloves and gowns were required prior to room entry. Additionally, the facility did not follow its water management policy and procedures. Chlorine level testing records showed multiple instances where chlorine levels were below the acceptable range, but there was no documentation of interventions or use of the Water Management Team Meeting Minutes form as required by policy. Furthermore, during peri-care for another resident with dementia and right-sided weakness following a stroke, a certified nurse aide placed soiled washcloths on the resident's over-bed table and did not clean or sanitize the table before leaving the room, failing to dispose of soiled linens in a sanitary manner.
Plan Of Correction
F tag 880 Infection Prevention and ControlSS=F 1. Staff member involved was immediately educated on the use of PPE for all residents in isolation. Soiled washcloths were immediately bagged and placed in the soiled utility room for laundering and the bedside stand disinfected. The water management meeting was held on 5/6/25. The following departments attended the meeting: Environmental Service Director, Maintenance, Infection Control (IC), Nursing, and NHA. 2. Residents residing in the house are at risk related to the deficient practice. Residents in the house were reviewed by the nursing team to ensure there was no spread of infection for failure to follow proper IC protocols when entering a room without proper PPE, no s/sx of legionella, and lack of proper handling of linen. The city's water department was contacted regarding the chlorine levels that were noted to be outside of parameters. A visit is scheduled for the week of 5/12 to test the facility's chlorine levels, using their device. If it is determined that the results are not within parameters, we will work with the water dept to regulate chlorine levels to appropriate parameters. 3. The QAPI Committee reviewed the policies and procedures related to Multi Route Transmission Based Precautions, Infection Control, and the Water Management Program and deemed it appropriate. Facility staff were re-educated by the DON/Designee on Multi Route Transmission Based Precautions and Infection Control. Staff who have not been educated by the Date of Compliance will be re-educated prior to returning to work. The Maintenance Director and ICP were re-educated on the water management program and the requirement of monthly meetings. The Maintenance Director was educated that if levels are not within parameters, an action plan needs to be developed and implemented to include rechecks on the levels. 4. The Infection Control Preventionist/Designee will observe 5 residents on isolation weekly times four weeks to ensure that staff are adhering to all IC protocols including Donning and Doffing PPE, handling of linen, water management program, then monthly for 3 months. The results of these audits will be forwarded to the QAPI Committee for further direction and guidance. The IC Preventionist is responsible for ongoing compliance. The NHA will review the monthly Water Management meetings to ensure that chlorine levels are within parameters. The NHA is responsible for ongoing compliance of the Water Management Program.