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 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.
A wound nurse did not consistently perform hand hygiene or use required PPE during a dressing change for a resident on Enhanced Barrier Precautions. The nurse failed to clean hands between glove changes, did not perform hand hygiene after removing gloves and gown, and did not don a gown when returning to complete wound care, contrary to facility policy and CDC guidelines.
A resident was hospitalized and tested positive for Legionella, but the facility did not follow its own water management plan by failing to test or remediate the water system, nor did it document control measures as required. Staff confirmed that a humidifier, which was prohibited by policy, was used in the resident's room, and water samples from the device were not tested. These lapses in infection control procedures exposed all residents to potential Legionella risk.
Staff failed to follow facility policies on Enhanced Barrier Precautions (EBP) and cleaning of a glucometer. Two residents requiring EBP due to wounds, a PICC line, and a Foley catheter received high-contact care from staff who wore gloves but not gowns, contrary to policy. Additionally, a glucometer was observed with dried residue, indicating it was not disinfected after use as required.
The facility did not implement or annually review its water management program, failing to specify or document control measures for multiple at-risk areas such as water heaters, pipes, faucets, and medical equipment. Key staff could not identify the standards used to develop the program, and the Legionella Policy had not been updated since 2018, potentially affecting all residents.
A resident on contact precautions for C. diff continued to have loose, uncontained bowel movements, yet staff failed to follow required infection control procedures. A laundry staff member entered and exited the resident's room without proper hand hygiene and was unaware of the contact precautions, while other staff were unclear about the resident's status. Facility policy required use of gowns, gloves, and handwashing, but these were not consistently followed.
An LPN administered insulin to one resident using another resident's previously used insulin pen after the second resident ran out of their own supply. This action, confirmed by staff interviews and medication records, violated both manufacturer instructions and facility policy, which prohibit sharing insulin pens between residents due to the risk of bloodborne pathogen transmission.
A resident received wound care from an LPN who failed to disinfect scissors between uses and did not change gloves between removing old and applying new dressings on two separate wounds. These actions did not follow the facility's infection control policies or CDC guidelines.
Staff did not follow infection control protocols during wound care for two residents, including failing to use clean field barriers and required PPE under Enhanced Barrier Precautions. Additionally, the facility lacked a water management plan specific to its actual water system, as required by policy.
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