Failure to Follow Infection Control Protocols and County Guidance for Legionella Surveillance
Penalty
Summary
The facility failed to consistently follow infection control standards, practices, and protocols, as well as to implement an effective infection control surveillance program. During a medication administration for a resident on Contact Precautions, an LPN was observed wearing an isolation gown and mask into the resident's room, then exiting the room and preparing medications at the medication cart while still wearing the same gown and mask. The LPN only removed the PPE after leaving the area for the second time, contrary to facility policy and infection prevention protocols, which require all PPE to be removed before exiting a Contact Precaution room. The Infection Preventionist confirmed that PPE should not be worn outside the resident's room. Additionally, the facility failed to follow guidance from the county health department regarding enhanced monitoring and testing for legionella. The county epidemiologist had provided specific criteria for enhanced legionella testing, including monitoring for clinical symptoms such as acute onset of lower respiratory illness with fever and/or cough. Despite this guidance, the facility did not identify or conduct enhanced legionella testing for multiple residents who met the criteria, as documented in the facility's infection surveillance logs and resident medical records. Several residents exhibited symptoms such as cough, shortness of breath, congestion, and pneumonia, but enhanced testing was not performed. Interviews with the Infection Preventionist, DON, and Administrator revealed a lack of communication with the health department and a failure to implement the recommended clinical criteria for legionella testing. The facility had instead adopted its own criteria, testing only residents with a fever of 102 degrees or above, which did not align with the county's recommendations. No explanation or additional documentation was provided by the facility for not following the health department's guidance.