Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to implement and maintain proper infection prevention and control measures according to current guidelines and professional standards for two residents. For one resident with an indwelling urinary catheter and requiring maximal assistance, staff did not consistently use Enhanced Barrier Precautions (EBP) during high-contact care activities such as emptying the urinary catheter drainage bag and transferring the resident. Observations showed that staff either did not wear protective gowns as required or were unclear about when EBP should be used, despite CDC signage indicating the need for gowns and gloves during specific care activities. Additionally, the resident's care plan did not include interventions related to EBP, and the facility's infection control policy lacked procedures for EBP use. Another resident with end-stage renal disease, dementia, and a deep tissue injury was observed receiving wound care without staff donning gowns for EBP, as indicated by posted CDC guidance. During the wound care procedure, the nurse failed to maintain aseptic technique, including contaminating sterile supplies with gloved hands that had touched environmental surfaces, and retrieving gloves from a scrub pocket considered unclean. The nurse acknowledged these lapses in infection control practices during an interview. The facility also lacked an active and ongoing plan to reduce the risk of Legionella and other opportunistic pathogens in the water system. Observations revealed stagnant water lines, unused fixtures, and discolored water from infrequently used faucets. Staff interviews confirmed the absence of a routine flushing schedule for water fixtures and no environmental water testing as part of the water management program. The facility's water management policy referenced control measures and corrective actions but did not specify their implementation or documentation.