Deficient Water Management and PPE Use for Infection Control
Penalty
Summary
The facility failed to maintain an active and ongoing infection prevention and control program, specifically in relation to its Water Management Plan (WMP) and the use of Enhanced Barrier Precautions (EBP). Upon request, the Administrator provided a Legionella Surveillance policy and a Water Management Program document, but the latter was a generic template not tailored to the facility. The WMP lacked essential components such as a diagram or description of the building water system, a risk assessment, identification of areas where Legionella could proliferate, control points, monitoring evidence, and documentation of routine water management team meetings. Interviews with the Maintenance Supervisor and Infection Preventionist revealed a lack of involvement and understanding regarding the WMP, with both staff members being relatively new and unable to provide details about the program or its primary prevention strategies. Additionally, nursing staff did not consistently use appropriate PPE for EBP. During an observation, an LPN entered a resident's room with an EBP warning sign indicating the need for gown, gloves, and mask during high-contact activities, but failed to don any PPE while checking a feeding tube. The LPN was unaware of the EBP signage and unsure about PPE requirements for tube feeding placement checks. The Unit Manager confirmed that staff are expected to know the location of precaution signs and the corresponding PPE requirements, while the NHA/DON stated that PPE should be worn during high-contact activities to prevent infection control issues.