EXCELSIOR SPRINGS, MO - Federal inspectors documented serious infection control deficiencies at Valley Manor and Rehabilitation Center during a July 2024 inspection, finding that staff failed to implement proper protective measures for high-risk residents and lacked adequate antibiotic monitoring programs.
Critical Breakdown in Enhanced Barrier Precautions
The most significant violation involved the facility's failure to implement Enhanced Barrier Precautions (EBP) for residents who required these specialized infection control measures. These precautions are designed to prevent the transmission of multidrug-resistant organisms (MDROs) and require staff to wear gowns and gloves during high-contact care activities.
Three residents were identified as requiring enhanced precautions but receiving inadequate protection. Resident #34, who had severe dementia and required total care including feeding through a gastric tube, should have been under enhanced precautions due to the indwelling medical device. Similarly, Resident #63, who had a urinary catheter and required total care, needed these additional protections. Most concerning was Resident #23, who had a documented history of multidrug-resistant organisms and infected surgical hardware from a hip repair.
Despite clear medical indications for enhanced precautions, inspectors found no identification signs outside these residents' rooms, no care plans addressing infection prevention protocols, and no resources to alert staff about required protective equipment. The failure to properly identify and protect these vulnerable residents created significant risks for disease transmission throughout the facility.
Staff Knowledge Gaps Pose Safety Risks
Interviews with nursing assistants revealed alarming gaps in basic infection control knowledge. When asked about enhanced barrier precautions, one nursing assistant stated they "did not know what enhanced barrier precautions was" and was "not sure if resident #34, #63 should be on isolation." Another staff member "did not believe that resident #34 or #63 should be on isolation, and was not told that in report."
These knowledge deficits are particularly concerning given the medical conditions of the affected residents. Gastric feeding tubes and urinary catheters create direct pathways for bacteria to enter the body, making proper infection control protocols essential. When staff are unaware of these risks or proper procedures, residents face increased chances of developing serious infections that could lead to sepsis, prolonged hospital stays, or death.
The medical significance of these violations extends beyond the immediate residents involved. MDROs can spread rapidly through healthcare facilities when proper precautions are not followed. These antibiotic-resistant bacteria are particularly dangerous because they are difficult to treat and can cause severe infections in vulnerable populations like nursing home residents.
Hand Hygiene Failures During Critical Care
Inspectors documented a separate but equally serious violation involving improper hand hygiene during personal care. During observation of care for Resident #58, who had diabetes, heart conditions, and a urinary catheter, staff failed to follow basic hand washing protocols multiple times during a single care episode.
The nursing assistant was observed removing gloves after cleaning fecal material without washing hands before putting on new gloves, then repeating this error again during the same care session. This creates a direct pathway for bacterial transmission from contaminated areas to clean areas of the resident's body, particularly dangerous for someone with a urinary catheter.
Hand hygiene represents the most fundamental infection control measure in healthcare settings. The Centers for Disease Control and Prevention identifies proper hand washing as the single most effective way to prevent healthcare-associated infections. When staff skip this critical step, especially during intimate care involving bodily fluids, they significantly increase the risk of introducing harmful bacteria into sterile body systems.
For residents with indwelling medical devices like catheters, improper hand hygiene can lead to catheter-associated urinary tract infections (CAUTIs), which can progress to kidney infections or bloodstream infections. These complications can be life-threatening for elderly residents with multiple chronic conditions.
Antibiotic Stewardship Program Deficiencies
The inspection also revealed that Valley Manor lacked an effective antibiotic stewardship program, despite having a policy dating to 2016. Federal regulations require nursing homes to monitor antibiotic use to prevent the development of resistant organisms and ensure appropriate prescribing practices.
The Director of Nursing acknowledged that "the antibiotic tracking book I have doesn't have much information in it" and was "unsure at the time of the interview who was on antibiotics or where data to show trends and antibiotic activity had been monitored and tracked in previous months."
Effective antibiotic stewardship programs are crucial for preventing the emergence of MDROs like those affecting Resident #23. When antibiotics are used inappropriately or monitoring is inadequate, bacteria can develop resistance, making future infections much more difficult to treat. This creates a cycle where infections become increasingly dangerous and treatment options become limited.
The absence of proper antibiotic monitoring also means the facility cannot identify patterns of resistance or implement targeted interventions to prevent the spread of resistant organisms. This puts all residents at risk for acquiring infections that may not respond to standard treatments.
Medical Context and Industry Standards
Healthcare facilities are required to implement infection prevention and control programs that protect vulnerable residents from preventable infections. Enhanced barrier precautions were developed specifically to address the growing threat of multidrug-resistant organisms in healthcare settings.
Residents with indwelling medical devices face substantially higher infection risks. Gastric feeding tubes can introduce bacteria directly into the digestive system, while urinary catheters create a pathway for bacteria to reach the bladder and kidneys. Proper use of gowns and gloves during care activities creates a barrier that prevents staff from inadvertently transferring bacteria between residents or from contaminated surfaces.
The facility's infection control policy correctly identified hand hygiene as "the primary means to prevent the spread of healthcare-associated infections," but implementation fell short of this standard. Research shows that healthcare-associated infections affect approximately 1.7 million nursing home residents annually, with many of these infections being preventable through proper staff practices.
Additional Issues Identified
Beyond the major violations, the inspection revealed systemic issues with the facility's infection control program. Care plans failed to address infection prevention strategies for high-risk residents, and there was confusion among leadership about current protocols and requirements. The Director of Nursing and Assistant Director of Nursing both acknowledged being "unsure which resident's should currently be on enhanced precautions, and what the current criteria and recommendations were."
The facility also lacked proper documentation and tracking systems for antibiotic use, making it impossible to identify trends or implement improvements in prescribing practices. Staff education appeared inadequate, with multiple nursing assistants demonstrating lack of knowledge about basic infection control principles that are fundamental to safe resident care.
These deficiencies point to broader systemic issues with training, oversight, and quality assurance programs at the facility. When multiple staff members lack basic knowledge about infection control, and leadership is uncertain about requirements, it suggests inadequate training programs and insufficient ongoing education.
The violations at Valley Manor highlight the critical importance of robust infection control programs in nursing homes, where residents are particularly vulnerable to serious complications from preventable infections. Proper implementation of enhanced barrier precautions, hand hygiene protocols, and antibiotic stewardship programs are essential components of safe, quality care for nursing home residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Valley Manor and Rehabilitation Center from 2024-07-10 including all violations, facility responses, and corrective action plans.
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