Infection Control Failures in Water Management, EBP, Wound Care, and Respiratory Equipment
Penalty
Summary
The deficiency involves multiple failures in the facility’s infection prevention and control program, including the absence of a Legionella water management program. Review of the Infection Prevention and Control Program policy revealed no language addressing Legionella testing or prevention. When surveyors requested the water management program, the Maintenance Director produced an empty clipboard and stated he had never heard of a water management program. The DON and the Administrator both reported they were unaware that there was no water infection prevention program in place, although the Administrator produced a single Legionella test report from the prior year. Surveyors also identified failures to follow Enhanced Barrier Precautions (EBP) and aseptic wound care technique. A nurse administering alprazolam via a G-tube to a resident on EBP wore gloves but did not don a gown for this high-contact care involving an indwelling medical device, despite facility policy requiring gown and gloves for such activities. The nurse later acknowledged she should have worn a gown and stated she was not aware that PPE, including a gown, was required when administering medications via the G-tube, even though EBP signage was posted on the resident’s door. In a separate observation, the LPN responsible for wound, skin, and ostomy care performed dressing care for a resident with a Stage IV sacral pressure wound without disinfecting the treatment cart, bedside table, or bed surface before placing clean supplies. The LPN used the same pair of gloves to cleanse the wound and then handle clean supplies and apply CollaSorb powder and calcium alginate dressing, and washed a reusable wound cleanser bottle with soap and water while gloved before returning it to the cart. The resident with the Stage IV sacral wound had significant comorbidities, including type 1 diabetes mellitus with neuropathy and circulatory complications, chronic kidney disease stage 3A, cerebrovascular disease, and polyneuropathy. The care plan for this resident included goals and interventions focused on wound healing, infection prevention, and monitoring for signs of infection, with physician orders specifying cleansing with wound cleanser or normal saline, application of collagen and calcium alginate, skin prep to the periwound, and dressing changes three times weekly and as needed. During interview, the LPN reported no observed breaches in infection control, believed her actions were appropriate, and stated that hand hygiene was only required twice during the procedure, and that washing the wound cleanser bottle with soap and water was sufficient, which contrasted with the DON’s stated expectations for disinfecting equipment and performing hand hygiene. Additional observations showed an oxygen concentrator in use by another resident with a filter covered in fuzzy, thick, dry gray particles on multiple days, while staff interviews revealed uncertainty among CNAs, nurses, the unit manager, and the DON about who was responsible for cleaning oxygen machine filters, how often tubing was changed, and how often filters should be cleaned, despite the DON stating that the RT was supposed to follow up on all residents on oxygen.
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