Infection Control Deficiencies: PPE Use, Room Cleaning, and Water Management
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices within the facility. Staff did not use personal protective equipment (PPE) appropriately in rooms under droplet isolation precautions, which were required due to the presence of COVID-19 on the third floor. Observations included nurse aides and an LPN entering and working in isolation rooms wearing only surgical masks or incomplete PPE, despite signage indicating the need for gowns, N95 respirators, gloves, and eye protection. Additionally, a visitor was not properly educated or equipped with the necessary PPE before entering a droplet isolation room, as confirmed by staff interviews. The facility also failed to ensure proper cleaning of resident rooms after discontinuation of isolation precautions. Housekeeping staff reported that residents remained in their beds during the deep cleaning process, which prevented thorough disinfection of beds, mattresses, and bedframes, and bedding was not laundered as required. This was confirmed by both housekeeping and administrative staff, who acknowledged that the cleaning procedures did not align with facility policy for post-isolation room cleaning. Furthermore, the facility did not maintain a comprehensive water management program to monitor and mitigate the risk of Legionella bacteria in the water system. The nursing home administrator was unable to provide documentation of a Legionella water management plan, including monitoring, auditing, or mapping of high-risk areas within the facility's water pipes. This deficiency persisted for a full year, as confirmed by the administrator during the survey.
Plan Of Correction
Resident weren't directly affected with Personal Protective Equipment (PPE) usage. The residents were removed from their beds and rooms cleaned, and the water management plan will be completed. All residents will be removed from their beds when rooms are cleaned. Employees will be instructed on what the protocol is for infection control signs hanging on the doors. The Director of Nursing or designee will educate nursing staff on the protocol for entering and leaving an infectious room and on educating a visitor on the protocol when the resident units or rooms have the infectious signs posted. The Director of Environmental Services will educate their staff on cleaning an infectious room post-isolation and the proper protocol of removing the resident from the bed. The Director of Nursing or designee will audit infectious rooms and proper PPE usage weekly times 3 and monthly times 2. The Director of Environmental Services will audit room cleans for removal of residents weekly times 3 and monthly times 2. Results will be turned into the monthly Quality Assurance meeting.