Multiple Infection Control and Reporting Deficiencies Identified
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in a shower room, as feces were observed in the shower stall next to the chair and near the drain. Certified Nurse Assistants acknowledged the presence of feces and stated it was not in line with facility expectations, but the area was not cleaned promptly. A resident reported avoiding showers due to repeated observations of feces on the floor, opting for bed baths instead. Facility policy required showers to be cleaned and sanitized up to two times daily, but this was not adhered to during the observed incident. The facility also failed to follow proper reporting guidelines for a Legionella outbreak. After a resident was hospitalized and tested positive for Legionella, the facility communicated with the county health department but did not notify the state agency as required. Interviews with staff, including the DON and Executive Director, revealed a lack of awareness regarding the requirement to report such outbreaks to the state, despite facility policy mandating the reporting, investigation, and documentation of all resident events. The outbreak was resolved, and families, staff, and residents were notified, but there was no evidence of state notification. Additional deficiencies were observed in infection control practices during meal delivery and wound care. CNAs delivering meal trays did not sanitize their hands before or between deliveries, and one CNA donned gloves without prior hand hygiene before assisting a resident with food. During a dressing change for a resident with severe cognitive impairment and pressure ulcers, an RN failed to change gloves or sanitize hands between wound sites, did not use a barrier on the bedside table, and did not wear a gown or implement Enhanced Barrier Precautions (EBP) as required for residents with open wounds. Staff interviews confirmed inconsistent understanding and application of EBP and hand hygiene protocols, despite facility policies outlining these requirements.