Failure to Implement Legionella Prevention and Proper Infection Control During Incontinence Care
Penalty
Summary
The facility failed to establish and implement a Legionella prevention program as part of its infection prevention and control program. Review of the facility's water management documentation showed no evidence of an active Legionella prevention plan, no designated team members responsible for managing such a plan, and no documentation of control measures to prevent Legionella. During interviews, both the Maintenance Supervisor and the Administrator confirmed the absence of an implemented Legionella prevention plan and related control measures, despite the facility's policy outlining the need for a comprehensive water management program. Additionally, the facility did not ensure proper infection control practices during incontinence care for a resident under Enhanced Barrier Precautions. Observation revealed that a CNA provided catheter and incontinence care to a resident, then touched multiple surfaces and the resident's wheelchair without changing gloves or performing hand hygiene. The CNA also left the resident's room without washing or sanitizing hands, contrary to posted signage and facility policy requiring hand hygiene before leaving the room. The CNA later confirmed not changing gloves or sanitizing hands during and after care. The resident involved had a history of intracerebral hemorrhage, hemiplegia, morbid obesity, encephalopathy, and depression, and was always incontinent of bowel and bladder, requiring significant assistance with activities of daily living. Facility policies on Enhanced Barrier Precautions and hand hygiene were reviewed and found to require proper glove use and handwashing, which were not followed during the observed care event.
Plan Of Correction
F0880: Water Management Program Facility Name: Majestic Care of Middletown Survey Date: June 5, 2025 Tag Number: F0880 Deficiency: The facility failed to implement a Legionella prevention plan, designate responsible personnel, or document control measures. The facility completed a review of all water management plan engineering protocols, which were all in place as of 6/20/25 by the maintenance director. The infection control prevention team completed a review of all current residents with no findings related to the cited practice on 6/6/25. As a precaution, the ED and Maintenance Director conducted an immediate risk assessment and flushed all water outlets to reduce potential exposure. All members of the Water Management Program (WMP) will complete CDC Legionella Training by July 10. A Water Management Team has been established, including the Administrator, Maintenance Director, Infection Preventionist, and Environmental Services. The facility has developed and adopted a comprehensive Water Management Program (WMP) in accordance with CDC Toolkit and ASHRAE Standard 188. The WMP includes: a detailed building water system diagram, hazard analysis identifying areas at risk for Legionella growth, control measures such as temperature monitoring, flushing protocols, and disinfectant levels, monitoring procedures and corrective actions for deviations, and documentation and communication protocols. The WMP will be reviewed quarterly by the Water Management Team. Monthly logs will be maintained for all control measures by the Maintenance Director. The facility will conduct annual validation of the WMP, and Legionella testing if indicated. Findings will be reported to the QAPI Committee for oversight. Date of Compliance: July 10, 2025