Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by staff not adhering to hand hygiene protocols during care for two residents. In one instance, a CNA provided incontinence care to a resident with obesity and muscle weakness, handling soiled linens and performing resident care tasks without changing contaminated gloves or washing hands before touching clean items and leaving the room. The CNA also touched doors and other surfaces with soiled gloves before eventually returning to wash hands, confirming during interview that hand hygiene was not performed as required. The facility's policy specified that hand hygiene should be performed after contact with soiled items and before leaving a resident's room. Another deficiency was observed when a CNA assisted a resident with severe cognitive impairment and multiple medical conditions with eating, without performing hand hygiene upon entering the dining room or before providing feeding assistance. The CNA confirmed during interview that hand hygiene was not performed prior to assisting the resident. The facility's policy and CDC guidelines both require hand hygiene before resident contact and after exposure to potentially contaminated surfaces or items. Additionally, the facility's Water Management Program (WMP) for Legionella prevention was found lacking, as it did not include a flow diagram or written description of the building's water system. The Director of Plant Maintenance confirmed that no such documentation had been developed, and there was no evidence that all critical control points were being monitored. The facility's policy did not address the need for a flow diagram or text description, despite CDC guidance requiring these elements to identify areas where Legionella could grow and spread.