Failure to Conduct Legionella Testing and Adhere to Contact Precaution Protocols
Penalty
Summary
The facility failed to follow standard infection prevention and control practices in two key areas. First, the facility did not conduct required quarterly testing of its water system for legionella bacteria, as indicated by the absence of testing on several documented dates. The Safety and Security Manager confirmed that the facility's water was not tested for legionella on multiple occasions, despite a previous request to begin such testing and a water management program recommending quarterly sampling. The Director of Nursing was unaware that the testing had not occurred, and the facility's water management plan outlined the need for routine monitoring and sampling. Second, a Licensed Vocational Nurse did not adhere to contact precaution protocols while providing respiratory care to a resident on contact and enhanced barrier precautions. During a suctioning procedure for a resident who was coughing, the nurse failed to wear an isolation gown as required by the facility's policy for contact precautions. The nurse acknowledged the omission and stated an attempt was made to avoid close contact, despite the policy specifying the use of gloves and gowns when entering the room of a resident on contact precautions, especially when substantial contact with the resident or their environment is anticipated.