Failure to Follow Legionella Control Measures and Infection Prevention During Wound Care
Penalty
Summary
The facility failed to follow its established Legionella control measures as part of its infection prevention and control program. Specifically, the facility did not obtain or log water temperatures for resident rooms and did not perform water flushing in unoccupied resident or shower rooms, contrary to its stated control measures. The Maintenance Director confirmed that there was no log of empty rooms, no flushing of unoccupied rooms regardless of the duration of vacancy, and no ongoing water temperature testing in resident rooms. Additionally, the facility lacked a formal Legionella policy beyond the general control measures outlined in its infection prevention and control program. During a wound care observation, an LPN did not adhere to infection prevention procedures as outlined in the facility's clean dressing change policy. The LPN removed a soiled dressing from a resident's right heel, disposed of it, and then, without removing gloves, handled a saline bottle and a four by four gauze. After cleansing the wound, the LPN removed her gloves but did not perform hand hygiene before donning a new pair of gloves and continuing the dressing change. The LPN acknowledged these lapses in infection control during a post-procedure interview. The resident involved had multiple diagnoses, including diabetes mellitus, chronic ulcer, and chronic osteomyelitis, and required extensive assistance with daily activities.