The facility failed to include personal humidifiers in its Water Management Plan. The Legionella Water Management Program and staff education materials identified humidifiers as a possible source for Legionella exposure, but observations on multiple units found humidifiers in resident rooms and the Water Management Program did not list them or include controls to prevent growth of Legionella and other opportunistic waterborne pathogens. The IP confirmed humidifiers were in use but not included in the plan.
Failure to Follow Water Management Plan: The facility did not carry out required water management controls in its Legionella program. Records showed multiple hot water outlet temperatures below the acceptable range in several areas, and the Maintenance Supervisor stated the facility could not provide required flush logs or biweekly hot water tank, chlorine residual, and pH logs. No corrective action had been taken for the out-of-range temperatures.
Failure to follow EBP PPE requirements was identified for two residents. One resident had EBP orders due to open wounds and a pressure injury, and staff were observed assisting with dressing and transfers while wearing gloves but no gown despite signage requiring both for high-contact care. Another resident with a history of ESBL and an EBP care plan was observed during linen care and dressing assistance with gloves only, and the LNA confirmed the gown was not worn.
Infection control practices were not followed for a resident on contact precautions and during an insulin medication pass. Staff entered the resident’s room without the required PPE, failed to remove gloves appropriately, and an LPN did not perform hand hygiene after removing gloves before preparing another resident’s medications. The facility also did not follow its Legionella water management monitoring requirements, including boiler temperature tracking, resident room temperature checks, and documentation of flushing for empty rooms.
The facility's Legionella water management plan did not include an assessment identifying where Legionella or other opportunistic waterborne pathogens could grow and spread, and it also lacked interventions for when control limits were not met. The policy required hot water temperatures to be maintained between 116 and 120 degrees Fahrenheit, and the DON confirmed the findings during interview. CDC guidance reviewed by surveyors stated that hot water should be stored above 140 F and circulating hot water maintained above 120 F, and that hazardous conditions should have control points, measures, limits, and corrective actions.
Failure to implement water management controls was identified after review of the facility’s Legionella surveillance policy and water management plan. The plan required hot water holding tank temperature checks, inspection for scale build up, biofilm, and other contamination, and monthly flushing, but the Mnt Dir confirmed there was no documentation that these measures were completed.
Failure to follow EBP and droplet precaution PPE requirements. A resident with an indwelling Foley catheter and pressure injuries had EBP posted, but a COTA assisted with clothing changes without a gown. Several staff entered rooms of residents on droplet precautions without the PPE required by posted signs and policy, including a LNA, Maintenance Director, RN, and Laundry Aide; one staff member also left a room without discarding a used mask.
EBP was not implemented for two residents with pressure ulcers, as there was no EBP signage, PPE setup, or care plan indication for high-contact care activities. During a wound dressing change, an LPN changed gloves but did not perform hand hygiene after glove removal. The facility also could not show evidence of legionella-related water management actions, and several infection prevention policies had not been reviewed annually.
Infection prevention and control failures were observed involving water management, EBP, TBP, and hand hygiene. The facility did not monitor hot water tank temperatures as outlined in its water management plan. Staff entered rooms of residents on EBP without the required gown during PICC and PEG-related care, and staff failed to follow contact and enteric precautions for residents with COVID-19, norovirus, and other contact precautions, including improper PPE use and incorrect hand hygiene. During wound care for a resident with pressure injuries, staff did not perform hand hygiene between glove changes and wound care steps as required by policy.
Infection Control Lapses During CBG Testing and Medication Pass: An LPN performed a CBG test using a glucometer with dried brown substance on it, then placed the used glucometer and supplies into the case while touching unused items inside. During med pass, the LPN wore the same gloves while touching multiple medication cards, bottles, the computer, and cart drawers, dispensed pills into his/her hands, and picked up a pill that had fallen on the medication cart.
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