Deficiencies in Infection Control Practices and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices, specifically regarding Legionella monitoring and annual updates to infection control policies. The Water/Wastewater Distribution System policy did not address Legionella, and the water management binder lacked identification of areas within the nursing home at risk for Legionella growth. Both the Infection Preventionist and Maintenance Director confirmed that there was no documentation or facility-specific information related to Legionella, and the binder contained only generic materials not tailored to the nursing home. Additionally, two infection control policies, the Antimicrobial Stewardship Program and the Antibiotic Stewardship Program, had not been updated annually as required. The facility also failed to implement Enhanced Barrier Precautions (EBP) for a resident with a chronic pressure ulcer. According to CDC guidance and the facility's own policy, EBP should be used for residents with chronic wounds such as pressure ulcers. However, the DON was initially unsure if EBP was necessary for the resident with a stage 1-2 wound and relied on the Infection Preventionist, who did not think EBP was needed. This resulted in a delay in placing the resident on Enhanced Barrier Precautions.