Inadequate Water Management and Improper Hand Hygiene During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide and implement an adequate infection prevention and control program in two key areas: water management and wound care practices. Surveyors reviewed a facility document titled "Premise Plumbing System" and found it contained only a diagram of the facility’s water system without any documentation identifying high‑risk areas where water pathogens might develop. During an interview, the Maintenance Director stated he had not previously seen a water flow diagram of the facility’s water system and confirmed that the diagram did not identify high‑risk areas for pathogen development. Review of ASHRAE guidance on managing the risk of legionellosis indicated that building water systems should be described using flow diagrams and written descriptions that include details such as where the building connects to the municipal water supply, how water is distributed and used, and the locations of water‑related equipment, highlighting that the facility’s existing water management program was incomplete and not consistent with this guidance. The report also identifies a deficiency in hand hygiene and glove use during wound care for one resident. The resident was admitted with a history of stroke and had a quarterly MDS showing a BIMS score of 0/15, indicating severe cognitive impairment. The assessment documented that the resident had a stage IV pressure ulcer, an unstageable pressure ulcer, and a venous stasis ulcer, and was receiving hospice services. Physician orders directed multiple daily wound treatments to several sites, including the left ischium, left lateral foot, left groin, left trochanter, right lateral foot, and sacrum, and the resident’s care plan indicated that wound care orders were to be followed. During observation of wound care, an LPN and the ADON were seen providing treatment to the resident. The LPN removed all existing dressings, then donned a single pair of gloves and used the same gloves while moving from wound to wound to cleanse each site with normal saline. After cleansing, the LPN changed gloves and sanitized her hands once, then applied the ordered treatments to all of the resident’s wounds while wearing the same pair of gloves, and repositioned the resident while still wearing those gloves before finally removing them and sanitizing her hands upon leaving the room. In a subsequent interview, the LPN stated she believed she only needed to change gloves and sanitize her hands between dirty and clean processes and was not aware she should change gloves and sanitize hands when moving from one wound to another to avoid cross‑contamination. The ADON stated she was unsure of the facility’s infection control process for wound care, while the DON stated her expectation was that infection control processes be maintained during wound care to prevent cross‑contamination and confirmed the LPN should have removed gloves and sanitized hands between wounds. The facility’s "Clean Dressing Change" policy indicated that, where sterile technique is not ordered, wounds are to be dressed using clean technique that avoids direct contamination of materials and supplies.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.