Infection Control Deficiencies: Training, Waterborne Illness Prevention, and PPE Compliance
Penalty
Summary
The facility failed to ensure that the infection preventionist was properly trained and knowledgeable in key infection control practices. The infection preventionist reported not receiving the required education for the position, was unable to provide documentation of hand hygiene and PPE audits, and was unsure about the frequency of mandatory infection control education. Additionally, the infection preventionist did not have quick reference materials for determining appropriate precautions for specific infections, was uncertain about which diseases were reportable to the state, and incorrectly stated that alcohol-based hand rubs were preferable to handwashing for Clostridioides difficile (C. diff) cases, contrary to CDC guidance. The facility also failed to implement and document safety measures to prevent waterborne illnesses such as Legionella. Staff interviews revealed that there was no log of toilet flushing or clear understanding of the requirements for weekly flushing to prevent Legionella growth. Testing for Legionella was limited to swab testing a countertop in the kitchen, and there was no evidence of a comprehensive water management program as outlined in facility policy, including monitoring, control limits, and documentation. Deficiencies were also observed in the application of transmission-based precautions and hand hygiene. One resident with C. diff was placed on droplet precautions, but staff entered the room without appropriate PPE, left the door open, and were unclear about the correct precautions. Another staff member failed to perform hand hygiene between glove changes while providing wound care to a resident, despite facility policy requiring handwashing after glove removal. These lapses in infection control practices had the potential to affect all residents in the facility.