Infection Control and Water Management Deficiencies Identified
Penalty
Summary
Surveyors observed multiple deficiencies in infection prevention and control practices within the facility. One incident involved a resident left unattended in a high, flat bed with a hoyer sling underneath and a foley catheter bag placed on their thigh, while no staff were present in the room or hallway. The resident reported feeling helpless after being left alone for five minutes. When a Geriatric Nursing Assistant returned, they failed to perform proper hand hygiene after handling the catheter bag and exited the room wearing gloves, discarding them improperly on top of a trash and dirty linen container before using hand sanitizer only after surveyor intervention. Both the Licensed Practical Nurse and Unit Manager acknowledged the concerns when informed by the surveyor. Another deficiency was identified regarding the facility's water management program. Upon request, the Maintenance Supervisor provided only water testing results, which showed previous positive results for Legionella, and described some remedial actions taken. However, neither the Administrator nor the Infection Preventionist were aware of an existing water management plan, and only an incomplete template was later provided, missing critical information such as the water management team, system inventory, and monitoring procedures. The Administrator eventually produced a contract for a water management company to create a plan, but at the time of the survey, a comprehensive plan was not in place. Additional infection control lapses were observed during medication administration and equipment use. An LPN failed to perform hand hygiene before entering and after leaving a resident's room with Enhanced Barrier Precautions signage, and sat on the resident's bed to administer medications, replacing a dropped pill without hand hygiene. Similarly, an RN did not clean a vital sign machine between resident uses and failed to perform hand hygiene when entering and exiting another resident's room, despite posted requirements. These actions were confirmed by direct observation and staff interviews.