Failure to Implement Infection Control Program and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement and document an effective infection prevention and control program, specifically regarding the mitigation of Legionella growth and the use of Enhanced Barrier Precautions (EBP) for residents with multidrug-resistant organisms (MDROs). During an interview, the Maintenance Director confirmed there was no documentation of flushing holding tanks or other areas prone to stagnant water, despite the facility's policy requiring surveillance and control measures for Legionella. The policy outlined the need to identify and monitor areas at risk for Legionella growth, such as storage tanks and water heaters, and to document control measures, but these actions were not carried out or recorded. For two residents with MDROs, staff did not follow the facility's EBP policy during high-contact care activities. One resident, who required total assistance with toileting and bathing and had an active MDRO in the urine, was observed receiving a shower from a nursing assistant who did not wear a gown as required by EBP protocols. The nursing assistant and another staff member confirmed that a gown should have been worn during this activity. Another resident with ESBL resistance and an indwelling urinary catheter was also not provided care in accordance with EBP. During catheter care, the nursing assistant performed hand hygiene and wore gloves but did not don a gown, despite EBP signage and policy requirements. The nursing assistant acknowledged that a gown should have been worn during the procedure. The facility's policy specified that EBP, including gown and glove use, must be followed during high-contact care for residents with wounds or indwelling medical devices.