Hand hygiene and EBP were not followed during resident care. An LPN administering IV cefazolin to a resident with a PICC line picked up a saline flush from the floor with an ungloved hand, changed gloves without hand hygiene, and continued IV prep and infusion tasks. In a separate event, an LNA transferred a resident with stage 3 pressure ulcers and removed linens while wearing gloves but no gown, despite EBP signage requiring both PPE items for those high-contact activities.
Glucometers Not Properly Cleaned and Disinfected: Two glucometers stored in a medication cart case were observed with dried red/brown substance adhered to them, and one also had tape on it. An RN confirmed the meters were ready for use. Facility policy and the manufacturer’s instructions required the meter to be cleaned and disinfected after use and wiped until visibly clean.
The facility failed to follow CDC laundry guidance when clean linen was stored in cardboard boxes on the dirty side of the laundry room, including on the floor near the doorway, behind the washer, and next to the rinse sink. The facility also did not update its water management plan after a water infection control risk assessment identified 2 water bubblers and different ice machine cleaning frequency, and the plan did not include hot water boiler/heater temperature monitoring or the required temperature controls for Legionella surveillance.
Water Management Program Not Updated or Implemented as Written: The facility failed to update its Water Management Program and did not implement required control measures for water outlets, closed drinking fountains, or resident humidifiers. Surveyors observed two lobby drinking fountains, learned they had been turned off and unused for months, and found empty rooms were flushed monthly instead of daily. An LPN confirmed a resident had a humidifier, and the IP stated resident humidifiers were filled with distilled water rather than the sterile water described in the program.
Failure to follow EBP occurred for a resident with a suprapubic catheter. Staff were observed providing bathing, dressing, personal care, and transfer assistance with gloves but no gown, and one staff member entered the room without gloves and a gown. The resident’s door had EBP signage, and the facility policy required PPE during high-contact activities such as bathing, dressing, transferring, hygiene, and urinary catheter care.
An LPN used one resident’s insulin pen to give insulin to another resident and then returned the pen to the cart, later using the same pen again after the error was discovered. In separate observations, the LPN did not perform hand hygiene between resident medication administrations, and another LPN did not clean and disinfect a shared glucometer before using it on a different resident. Facility policy and manufacturer guidance required single-patient use of insulin pens, hand hygiene during resident care, and disinfection of blood glucose meters after each use.
Failure to implement Legionella water management controls was identified after review of the facility's plan and policy and interview with the DOR of Maintenance. The facility had no documentation that required annual flushing of the hot water tank sediment or cleaning of shower heads, handheld wands, strainers, and pressure restrictors had been performed, despite these measures being listed in the Legionella Water Management Plan.
Infection control was deficient because a resident with an indwelling urinary catheter was not placed on EBP as required by facility policy, and PPE supplies and precaution signage were not present. The resident’s care plan included EBP, but staff were unaware of the status and used only gloves during care. The facility also had an incomplete water management plan that did not identify specific areas where Legionella could grow and spread, and documentation was lacking for required replacement of shower wands and kitchen hoses.
A resident received insulin from another resident’s used Lispro pen, and the hospital discharge summary documented accidental receipt of Lispro and Trulicity. The DON confirmed no bloodborne pathogen labs were done for either resident and the resident’s DPOA was not notified of the exposure risk. Facility policy and CDC guidance both state insulin pens are for one patient only.
Incomplete Water Management Plan: The facility’s water management plan did not include all required elements to prevent Legionella and other opportunistic waterborne pathogens. The plan lacked an accurate description of the water system, did not identify all areas where Legionella could grow and spread, and did not specify how to respond when control limits were not met. It also did not state how often hot water storage tank temperatures should be monitored, and the maintenance log showed no recorded tank temperatures. The IP and Administrator identified unused resident bathtubs and eyewash stations as additional low-use risk areas that were not included in the plan.
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