Infection Control Failures in Hand Hygiene, Water Management, and PPE Use
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures in several key areas. In the kitchen, disposable towels were not available at the employee handwashing sink, contrary to the facility's own sanitation and hand hygiene policies. This was confirmed through observation and staff interview, where the Certified Dietary Manager acknowledged that disposable towels should always be available and that staff are expected to coordinate with housekeeping to replenish them. Additionally, the facility had not implemented a water management program to reduce the risk of Legionella and other pathogens in the water system, as required by facility policy. The Maintenance Director confirmed that no such program was in place, although he possessed a copy of the CDC Toolkit related to water management. The facility also failed to ensure proper use of personal protective equipment (PPE) and hand hygiene during resident care. During an observation of wound care for a resident with a sacral pressure ulcer who was on Enhanced Barrier Precautions (EBP), two CNAs entered the resident's room to reposition her without cleaning their hands or donning gowns and gloves, as required by facility policy for residents with wounds. Both CNAs admitted in interviews that they did not use the required PPE or perform hand hygiene before repositioning the resident for wound care.