Failure to Implement Water Management and Infection Control Protocols
Penalty
Summary
The facility failed to implement and document an effective Water Management Program (WMP) to reduce the risk of Legionella in the water system. Review of the facility's Legionella Environmental Assessment Form revealed it lacked a description or diagram of the water system, and there was no documentation of required monthly chlorine testing or visual inspections for biofilm. The Maintenance Supervisor confirmed that these assessments and tests had not been completed, despite the facility's policy stating that such control measures and documentation were required. Additionally, the facility did not ensure proper infection prevention and control practices during a pressure ulcer dressing change for a resident with multiple comorbidities, including diabetes, hypertension, heart failure, and anemia. The resident had a pressure ulcer on the sacrum and buttocks, and physician orders required twice-daily wound care. During an observed dressing change, there was no Enhanced Barrier Precautions (EBP) signage or PPE cart outside the room, and the LPNs involved did not wear gowns as required by EBP guidelines for residents with wounds. The wound was also cleansed from the outside toward the center, contrary to recommended technique. Staff interviews confirmed that the required EBP protocols were not followed, including the use of gowns and the correct wound cleaning technique. The failure to follow these infection control measures and to maintain a comprehensive WMP had the potential to affect all residents in the facility, as confirmed by the census of 59 residents.