Failure to Implement Infection Control, Water Management, and Outbreak Reporting
Penalty
Summary
Staff failed to implement and maintain effective infection prevention and control practices in several areas. During observation, a resident with a catheter was found with the catheter bag lying flat on the floor on two separate occasions. A CNA stated that the bed did not have a place to hang the bag, so it was placed on the floor. Both the interim DON and ADON confirmed that catheter bags should not be placed directly on the floor. Additionally, the facility did not implement its water management program for Legionella, as required by its own policy, and failed to maintain logs or review data for trends or deficiencies. An outbreak of gastrointestinal illness involving 14 residents was not reported to the state licensing agency, despite the requirement to do so. The interim DON was unaware of the reporting requirement at the time of the survey.