Failure to Implement Enhanced Barrier Precautions and Maintain Water Management Controls
Penalty
Summary
The deficiency involves failure to properly implement enhanced barrier precautions (EBP) for a resident and failure to maintain an active, ongoing water management program to reduce the risk of Legionella and other opportunistic premise plumbing pathogens. A female resident with dependence on renal dialysis and a central venous port was under physician orders and care plan directives for EBP during high-contact care activities, including dressing, bathing, transferring, hygiene, linen changes, toileting/brief changes, and device or wound care. During observation, a CNA was seen scratching and rubbing the resident’s bare back and then repositioning her in bed without wearing gloves or a gown, despite acknowledging that the resident was on EBP and that PPE should have been used for this type of care. The Infection Control Preventionist confirmed that the resident was on EBP due to the central line and that PPE was required during such high-contact care activities. The deficiency also includes lack of a fully implemented water management program consistent with the facility’s own policy. The Maintenance Director reported that the water management plan was still a work in progress and that there were no established control measures and control limits in active use to reduce the risk of Legionella or OPPP, including no current sampling for disinfection levels. He stated that he maintained ice machines, cleaned the fountain in the summer, and flushed some taps every few days, but had not been flushing certain fixtures. Observation of a soiled utility room revealed a hopper with an attached hose sprayer and an over-hopper sink that had not been fully flushed; when the water was turned on, brown and discolored water came from both hot and cold lines and the sprayer. In a shower room, capped water lines extended several feet from the main water line and had not been flushed or removed. Review of the facility’s written Water Management Program and related documents showed that control measures, testing protocols, and control limits, including monthly disinfectant residual testing of hand sinks, showers, and whirlpool baths, were required but not being carried out as described.
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