Infection Control Failures Involving Legionella, COVID-19 Staff Return, and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, resulting in multiple deficiencies. One resident with severe cognitive impairment and a history of dementia, COPD, and stroke used a personal humidifier that was filled with tap water by staff and a family member. The facility did not have a policy or procedure for the use of humidifiers, nor did its water management program address humidifiers as a potential source for Legionella bacteria. The resident was diagnosed with Legionnaires' disease after being hospitalized for pneumonia, and subsequent investigation revealed that staff were unaware of the humidifier's presence and there was no documentation regarding its use or maintenance. The humidifier was later found to contain multiple bacteria, and water testing in the facility identified positive Legionella samples in a nearby unused whirlpool tub. The facility also failed to ensure that COVID-19 positive staff members returned to work in accordance with its own policy, which was intended to follow CDC guidelines. Review of staff records showed that several staff members returned to work earlier than recommended by the CDC, with return-to-work dates not aligning with the required isolation periods. Interviews with staff and management revealed confusion about the correct return-to-work protocols, with some staff believing a five-day isolation was sufficient, contrary to CDC guidance for healthcare personnel. Additionally, the facility did not implement enhanced barrier precautions (EBP) for a resident with an indwelling Foley catheter. There was no EBP signage or PPE cart outside the resident's room, and a CNA did not perform hand hygiene before donning gloves or wear a gown during catheter care. The CNA was unsure about the requirements for gown use during such care, and the DON confirmed that these actions were not in compliance with the facility's EBP policy.