Infection Control and Water Management Deficiencies Identified
Penalty
Summary
During a dressing change for a resident with multiple complex medical conditions, including acute respiratory failure, muscular dystrophy, and dependence on a ventilator, infection control measures were not properly implemented. The resident was under enhanced barrier precautions due to wounds, a tracheostomy, and a gastrostomy tube. Observation revealed that the nurse practitioner and an LPN wore gowns and gloves, but the nurse practitioner failed to perform hand hygiene or change gloves between handling two separate wound sites. The same gloves were used throughout the procedure, including while cleansing wounds, applying dressings, and repositioning the resident. The nurse practitioner confirmed during an interview that hand hygiene and glove changes should have occurred but were not performed. Facility policy required hand hygiene and glove changes between wound care steps, which was not followed in this instance. Additionally, the facility failed to adhere to its written water management plan for Legionella prevention. The plan required weekly water temperature checks at each water heater to ensure temperatures were maintained at 140 degrees Fahrenheit. However, review of logs showed that temperatures were recorded from faucets, not directly from the water heaters, and the recorded temperatures ranged from 100 to 119 degrees Fahrenheit over several months. The maintenance director confirmed that the procedure did not follow the facility's established water management plan.