Deficient Infection Control in Water Management and Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, resulting in multiple deficiencies related to both waterborne pathogen management and direct resident care practices. Specifically, the facility did not provide further testing for Legionnaires' disease for residents diagnosed with pneumonia, did not implement short-term water disinfection control measures after receiving positive Legionella test results in the potable water system, and did not report water samples exceeding 30% positivity for Legionella to the New York State Department of Health. These lapses were identified through record reviews and interviews, which revealed that seven out of ten water samples tested positive for Legionella at one point, and follow-up sampling was delayed. Additionally, there was no documentation of required disinfection measures, and key staff, including the Medical Director and Director of Nursing, were not informed of the positive Legionella results, preventing appropriate clinical follow-up for residents with pneumonia. In addition to water management failures, the facility did not ensure proper implementation of enhanced barrier precautions and standard precautions during resident care. For one resident with a suprapubic catheter and bowel incontinence, staff did not wear the required personal protective equipment (PPE), failed to perform hand hygiene or change soiled gloves after incontinence care, and placed the resident's catheter drainage bag directly on the floor without a barrier. Another resident with a nephrostomy tube was not placed on enhanced barrier precautions as ordered, and staff provided care without appropriate PPE or signage indicating the need for such precautions. A third resident, dependent on staff for toileting hygiene, received incontinence care from staff who did not change gloves or perform hand hygiene before touching clean linens and environmental objects. Interviews with staff confirmed a lack of adherence to infection control policies, with several staff members acknowledging that they did not follow required procedures for glove changes, hand hygiene, and PPE use. The Director of Nursing stated that residents with indwelling medical devices should be on enhanced barrier precautions and that staff should change gloves and wash hands after incontinence care. The absence of an infection preventionist contributed to inconsistent implementation of infection control measures, as responsibilities for signage and PPE availability were not clearly assigned.