Failure to Monitor Water Temperatures and Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure adequate temperature monitoring and documentation of its hot water tank and water storage tank, as required by its Water Management Plan (WMP). During interviews and record reviews, the Maintenance Director and Nursing Home Administrator confirmed that temperatures for the hot water generation and return systems were not being recorded, despite the WMP specifying weekly monitoring and documentation. The Maintenance Director acknowledged that this monitoring is necessary to ensure the mixer functions properly and to prevent risks such as scalding and Legionnaires Disease. No additional documentation or information was provided by facility leadership when requested during the exit conference. Additionally, the facility did not ensure that staff followed Enhanced Barrier Precautions (EBP) for a resident with a peripherally inserted central catheter (PICC) line and an open wound. Observations showed that registered nurses administered intravenous antibiotics and performed wound and hygiene care for the resident without wearing gowns, as required for high-contact care activities. Interviews with nursing staff and leadership revealed a misunderstanding of EBP requirements, with staff believing gowns were only necessary if the resident had tested positive for a multidrug-resistant organism. The resident in question had diagnoses including paraplegia, a stage IV sacral pressure ulcer, and osteomyelitis, and was cognitively intact at the time of the observations.