Failure to Implement Effective Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program as evidenced by multiple deficiencies in water management, meal service, and hygiene care. A resident reported a clogged sink in his restroom that had been left unaddressed for an extended period, as confirmed by maintenance logs and staff interviews. This issue prevented the resident from washing his hands prior to meals, and no alternative hand disinfectant was provided. During meal service, it was observed that a kitchen cook repeatedly handled a food thermometer and touched their apron before placing the thermometer back into food, indicating a lapse in proper infection control practices. Further investigation revealed that the facility lacked a comprehensive water management program, including policies and procedures for Legionella risk assessment, water system flow charts, testing of shower heads, and professional water testing for contaminants. The facility was unable to provide documentation of control measures, water quality parameter measurements, or plans for corrective action when control limits were not met. These findings were confirmed through interviews with the nursing home administrator and review of relevant policies and regulatory guidelines.