Inadequate Infection Control Practices and Missing Water Management Documentation
Penalty
Summary
Surveyors identified multiple failures in the facility’s infection prevention and control practices. Residents with devices that require Enhanced Barrier Precautions (EBP) did not have appropriate signage posted at their room doors, including a resident with a PEG tube and two residents with Foley catheters. Another resident on EBP for wound care had EBP signage on the door frame, but two licensed nurses entered without donning gowns and performed a buttock wound dressing change using only gloves. One of these nurses later stated she did not know if the resident was on EBP and acknowledged that the signage meant the resident was on EBP and that a gown should have been worn during the wound care. Surveyors also observed hand hygiene failures during perineal care when two CNAs removed soiled gloves and donned clean gloves without performing hand hygiene between cleaning the resident and applying a clean brief. Both CNAs confirmed they did not sanitize or wash their hands at that point, and one stated they had never really washed or sanitized their hands in between. Additionally, review of the facility’s water management documentation revealed no recorded dates or times for flushing stagnant water areas as part of Legionella prevention. The maintenance supervisor confirmed he was responsible for this documentation, had not recorded when flushing occurred, and was unaware that he was required to do so. Upon request, the facility was unable to provide an EBP policy or a Legionella policy, despite having an infection control policy stating staff would be educated on hand hygiene and other infection prevention practices.
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