Infection Control Program Deficiencies: Water Management, PPE, and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain a comprehensive infection prevention and control program, as evidenced by multiple deficiencies in water management, use of personal protective equipment (PPE), hand hygiene, and implementation of Enhanced Barrier Precautions (EBP). The facility did not have a current, comprehensive water management plan that included a complete team, facility-specific flow diagrams, or identification of risk areas and interventions to prevent the spread of opportunistic pathogens such as Legionella. Interviews with staff revealed a lack of understanding of the water management program, incomplete documentation, and absence of risk area identification on facility maps. Daily water temperature logs were maintained, but other critical elements of the water management program were missing or not clearly communicated among team members. Observations of staff providing care to residents revealed repeated failures to use proper PPE and adhere to EBP protocols. For a resident with a gastrostomy tube, staff were observed administering medications and providing care without wearing required gowns and, at times, without gloves. Hand hygiene was inconsistently performed before donning gloves or after removing them, and staff were seen reusing gloves or failing to change them between tasks. These lapses occurred despite clear signage and care plans indicating the need for EBP due to the presence of a gastrostomy tube. Similar failures were observed during wound care for another resident with an open pressure injury, where staff did not use gowns as required and did not consistently perform hand hygiene at appropriate times. Additionally, a resident with a stage 2 pressure wound was not placed on EBP as required, and staff performed wound care using only gloves without gowns. During wound treatments, staff were observed handling clean and soiled items without performing hand hygiene in between, and contaminated items were placed in clean bins before handwashing. Interviews with staff indicated a lack of understanding regarding the need for EBP for open pressure injuries. These deficiencies were directly observed by surveyors and confirmed through interviews and record reviews.