Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to implement and follow its infection prevention and control program in several key areas. During medication administration observations, a nurse did not don a gown as required by the facility's Enhanced Barrier Precautions (EBP) policy when providing direct care to a resident identified as needing enhanced precautions. The nurse acknowledged forgetting to wear the gown, and both the infection preventionist and another nurse confirmed that medication administration and taking vital signs are considered direct care activities that require the use of gowns and gloves under EBP. The facility's policy specified that EBP is used to prevent the spread of multi-drug-resistant organisms and requires targeted gown and glove use in addition to standard precautions. Additionally, another nurse failed to disinfect the vial top and injection ports with alcohol swabs during the preparation and administration of intravenous vancomycin for a resident. The nurse stated that disinfection was not necessary, which was contradicted by the infection preventionist and the facility's policy. The policy required strict aseptic technique, including disinfecting all injection ports with a sterile alcohol swab for at least 30 seconds before access. The facility's water management plan was also found to be insufficient. The plan lacked essential details such as a description of the building, the population it housed, and a comprehensive description of the water system. It did not identify areas where Legionella could grow and spread, nor did it include control measures or verification steps to ensure the plan was being followed. Interviews with facility leadership confirmed that the water management plan was not personalized or adequate for the facility's needs, and did not meet the requirements outlined in the facility's own policy and procedures.