Deficiencies in Water Management, Policy Updates, and Infection Control Practices
Penalty
Summary
The facility failed to maintain a comprehensive water management program as required by its own policies and procedures. The water management binder only contained results of random Legionella testing and daily water temperature checks in a limited number of locations, without documentation of procedures for out-of-range temperatures, diagrams of the water system, or identification of all areas where water may collect or flow. There was no interdisciplinary water management team meeting routinely, nor a system to identify situations that could lead to Legionella growth, such as biofilm or sediment buildup. Interviews with the Infection Prevention Nurse and Maintenance Supervisor confirmed these gaps and the absence of a complete water management plan as outlined in facility policy. The Infection Prevention and Control Program (IPCP) policies and procedures were not current or reflective of national standards. The policy on staff COVID-19 vaccination was outdated, still requiring vaccination, booster, and additional testing or masking for unvaccinated staff, despite current practice and regulations no longer mandating these measures. The administrator acknowledged that the policy had not been updated and that staff were not required to provide evidence for vaccine refusal, nor were they subject to additional testing or masking, contrary to the written policy. The facility's process for policy review was also found to be ineffective in ensuring policies remained current and aligned with regulatory requirements. Additionally, staff failed to follow infection control protocols during wound care preparation for a resident with multiple complex medical conditions, including an unstageable pressure ulcer, diabetes, dementia, and quadriplegia. A treatment nurse was observed disinfecting the resident's bedside table and preparing wound care supplies without wearing gloves, in direct violation of the facility's policy on glove use. The nurse acknowledged the lapse and the potential for transferring bacteria to the resident's wound, which could result in infection.