Infection Control Program Deficiencies: Legionella Response, Equipment Storage, and PPE Compliance
Penalty
Summary
The facility failed to implement an effective infection prevention and control program in several key areas. During an investigation of a possible Legionella outbreak, the facility did not fully follow local public health recommendations. The Executive Director (ED) and Director of Maintenance (DM) acknowledged that not all recommendations from the Department of Health (DOH) were implemented, such as obtaining professional consultation from water system experts, conducting post-remediation testing, installing point-of-use filters, and notifying residents and families about the ongoing investigation. The facility's water management plan was not updated in a timely manner, and there was a lack of documentation and monitoring of water temperatures at distal locations. The DM had not performed Legionella testing or assessments during his tenure, and water temperatures in some areas were below recommended levels. Observations revealed additional infection control lapses. Respiratory equipment, such as nasal cannula tubing, was not stored in a clean and sanitary manner, with tubing found wrapped around an emergency tank and lying on a wheelchair seat without proper storage. Staff were unable to identify the owner of the tubing, and the Director of Nursing/Infection Preventionist (DON/IP) confirmed that the expectation was for such equipment to be stored in a bag. Furthermore, a blanket was observed on the floor under a PTAC unit to absorb water, which the DON/IP stated was not appropriate. The facility also failed to ensure proper use of personal protective equipment (PPE) and appropriate signage for transmission-based precautions. In one instance, a provider entered a resident's room on contact isolation for ESBL/UTI without donning PPE, despite a caddy and sign indicating the need for precautions. In another case, a room with a resident on contact isolation for C. difficile lacked signage specifying the type of precautions, even though PPE was available outside the door. The DON/IP acknowledged that staff had been educated on these requirements and that signage should not be moved, but these expectations were not consistently met.