Failure to Implement Enhanced Barrier Precautions and Water Management Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by multiple lapses in the implementation of Enhanced Barrier Precautions (EBP) and the absence of a water management plan. Specifically, during wound care for a resident, a nurse did not wear a gown as required by EBP protocols, despite signage indicating the need for such precautions and the availability of gowns and gloves outside the resident's room. The nurse acknowledged the omission, and the Director of Nurses confirmed that residents with wounds require both gown and glove use during dressing changes. In a separate instance, another resident with a wound did not have EBP signage posted on their doorway, and a nurse performed a dressing change using only gloves, omitting the gown. Both the nurse and the Director of Nurses recognized that EBP should have been implemented and followed for this resident. Additionally, the facility did not have documentation or a plan in place to prevent the growth of Legionella and other waterborne pathogens in the building's water systems. Both the Maintenance Director and the Infection Control Nurse were unable to provide a water management plan when requested. The CDC guidelines referenced in the report recommend comprehensive water management programs to reduce the risk of Legionella growth and transmission, but the facility lacked evidence of such measures.