Failure to Update Water Management Plan and Implement Infection Control Precautions
Penalty
Summary
The facility failed to maintain and update its Legionella water management plan, as evidenced by the use of an outdated plan last revised in 2018, which still contained the names of former staff and had the facility's current name handwritten over the previous one. Required routine monitoring activities, such as fixture flushing, water temperature checks, and other water safety measures, had not been documented or completed since August 2024. This lapse was confirmed by the Divisional Director of Clinical Operations, who acknowledged the lack of updates and monitoring logs. Additionally, the facility did not implement appropriate infection control precautions for residents with specific needs. One resident who tested positive for C. difficile did not have any contact or isolation precautions ordered or implemented, and there was no signage or personal protective equipment (PPE) available at the room entrance, contrary to facility policy requiring high-level contact precautions for such cases. This was confirmed by both medical record review and staff interviews. The facility also failed to ensure staff adherence to enhanced barrier precautions (EBP) for residents with indwelling medical devices. Observations showed that staff did not wear gowns during high-contact care activities for residents with urinary catheters, tracheostomies, or feeding tubes, despite posted EBP signage and existing physician orders. Staff interviews revealed a lack of awareness regarding EBP requirements, and policy review confirmed that gowns and gloves should be used during specified care activities for these residents.