Inadequate Infection Control Program and Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain a comprehensive infection prevention and control program, as evidenced by incomplete policies, lack of required documentation, and improper implementation of enhanced barrier precautions (EBP). The facility's Legionella Policy and Procedure for Water Management did not include a detailed flow diagram of the water system, and the Maintenance Director was unable to provide such a diagram or specific corrective actions for situations when Legionella control measures were not met. Additionally, infection control policies were not reviewed or updated annually, and several policies lacked current information, such as updates on pneumococcal and influenza vaccines, procedures for staff who refuse vaccinations, and a comprehensive list of communicable diseases that must be reported to the health department. Staff failed to implement EBP as required for residents with wounds or non-intact skin. One resident, who had a percutaneous endoscopic gastrostomy (PEG) tube removed and was on EBP due to open skin, was observed receiving high-contact care, including linen changes and shaving, from two CNAs who did not wear personal protective equipment (PPE). The CNAs were unclear about when PPE was required, and one CNA stated that PPE was only necessary when in direct contact with the wound dressing, despite the resident being on EBP for a wound. The Director of Nursing confirmed that PPE should have been used during these high-risk tasks. Another resident with a chronic wound that reopened was not placed on EBP until three days after the wound was identified. During this period, staff were observed providing care without PPE, and there was no EBP signage or PPE cart outside the resident's room. The Director of Nursing verified that EBP should have been implemented immediately when the wound reopened, but this did not occur until several days later.