Deficiencies in Water Management and Infection Control Practices
Penalty
Summary
The facility failed to maintain an active and ongoing Water Management Program Plan (WMPP) to reduce the risk of Legionella and other opportunistic pathogens in the plumbing system. The WMPP required the establishment of a Water Management Team, including the Administrator, Maintenance Director, and Infection Preventionist, to implement policies, monitor performance, and review the program annually. However, interviews revealed that the Infection Preventionist and Administrator were not actively involved, with responsibilities deferred entirely to the Maintenance Supervisor. The plan had not been updated since 4/29/23, and required monitoring activities such as Point of Use Residual Disinfectant checks and fixture flushing logs were not being completed or documented, as confirmed by the Maintenance Supervisor. The facility also failed to ensure proper use of Personal Protective Equipment (PPE) during isolation precautions and did not complete departmental infection control surveillance. Observations showed that staff providing care to a resident on Enhanced Barrier Precautions (EBP) wore only gloves, not gowns as required by signage and physician orders, during high-contact activities such as bathing, brief changes, and PEG tube care. Additionally, a nurse was observed failing to perform hand hygiene during a medication pass. The Infection Control Preventionist confirmed that the required PPE was not used and that there was no documentation of monthly departmental infection control surveillance. The resident involved in the PPE deficiency had significant medical needs, including non-traumatic brain dysfunction, stroke, high blood pressure, severely impaired cognition, impaired range of motion, and total dependence on staff for activities of daily living. The resident was on EBP due to a PEG tube and had previously been on contact precautions for a stool-borne pathogen. The facility's infection surveillance policy required monthly data analysis and presentation to the QAPI committee, but no such documentation was available at the time of the survey.