Failure to Implement Infection Control and Water Management Policies
Penalty
Summary
Surveyors observed that staff failed to follow established infection prevention and control policies during wound care for two residents. Specifically, the infection preventionist and an advanced practice registered nurse gathered wound care supplies on an uncleaned clipboard without using a clean field barrier, and entered rooms marked for Enhanced Barrier Precautions (EBP) without donning isolation gowns. During wound care, contaminated items such as scissors were placed on the clipboard and then returned to the treatment cart without proper cleaning. These actions were confirmed by staff interviews and were not in accordance with the facility's policies, which require the use of gowns and gloves for high-contact care activities like wound care, and the establishment of a clean field for dressing changes. Additionally, the facility failed to develop and implement a water management program tailored to its actual water system. The provided water management plan described a four-story building, while the facility is only one story, and did not accurately reflect the flow of the water system. The administrator confirmed the absence of a water management plan specific to the facility, despite policy requirements for such a program as part of the infection prevention and control program.