Failure to Implement Infection Control Policies and Water Management Program
Penalty
Summary
The facility failed to implement and follow its own infection prevention and control policies, specifically regarding Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling medical devices. Observations during the survey revealed that staff did not use required personal protective equipment (PPE), such as gowns and gloves, during high-contact care activities for residents with chronic wounds, central venous catheters, or feeding tubes. There were no signs posted to indicate PPE requirements, and PPE was not readily available for use. Specific incidents included a nurse aide providing care to a resident with a central venous catheter without a protective gown, an LPN flushing a feeding tube without a gown, and the same LPN providing wound care to a resident with a Stage 4 pressure sore without using a gown. The Infection Preventionist confirmed that the EBP policy had not been implemented or followed by staff. Additionally, the facility did not have a documented water management program for Legionella, as required by its Emergency Preparedness Plan and Infection Control Policies. There was no evidence that the facility's water had been tested for Legionella, and the Administrator confirmed the absence of a documented water management program. These deficiencies were found to have the potential to affect all residents in the facility.