Failure to Follow Enhanced Barrier Precautions and Lack of Legionella Water Management Plan
Penalty
Summary
The deficiency involves the facility’s failure to follow its Enhanced Barrier Precautions (EBP) policy during wound care and its failure to develop and implement a specific water management plan for Legionella. Resident #17, who was severely cognitively impaired and had moderate depression, had multiple diagnoses including Alzheimer’s disease, chronic kidney disease, diabetic retinopathy, and a kidney transplant, and had an infected diabetic foot ulcer on the left foot requiring daily wound care with normal saline cleansing, calcium alginate, and a bordered foam dressing. The resident’s care plan documented that EBP had been implemented due to the infected left foot wound, and the facility’s EBP policy required gown and glove use for any wound care or skin opening requiring a dressing. During observation, an RN gathered wound care supplies, placed them on the bedside table, left and re-entered the room without any PPE, and prepared to remove the resident’s foot dressing. When questioned, the RN stated she believed the resident was on EBP but thought PPE was only required for direct patient care and was unsure if wound treatment qualified, indicating a failure to don required gown and gloves before performing wound care. The deficiency also includes the facility’s failure to have a functional water management plan addressing Legionella risk. The only document provided, titled “Policy and Procedure: Water Management Plan – Legionella,” was a general guide on developing a water management plan and listed commonly used control measures but did not specify what actions the facility itself was taking to reduce the risk of Legionella. In an interview, the Administrator confirmed that this document was the only water management plan available and was unable to provide any information about actual measures used by the facility, demonstrating that no specific, implemented plan for Legionella control was in place. This non-compliance was investigated under Complaint Number 2718794.
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