Construction of a Violation/Deficiency Example

Here is an example of a deficiency/violation containing all three components. Each component is labeled.

 

(Regulatory Reference)

W455  483.470(l)(1), "There must be an active program for the prevention, control, and investigation of infection and communicable disease." 

This requirement was not met as evidenced by:

 

(Deficient Practice Statement)

Based on observation and interviews, the facility failed to prevent cross-contamination during meals for 6 of 6 individuals (Individuals #'s 1 - 6).

 

(Relevant Findings/Evidence)

Observations on 7/14/16 from 5:40 p.m. – 6:02 p.m. in the facility's dining room revealed that Individual #1 wiped his nose with alternating hands and coughed into his palms while setting the table.  Individual  #1 touched the eating surfaces of the forks and spoons as he placed all six individuals' silverware onto the table. The house manager and Direct Care Staff (DCS) A were in the room, approximately 10 feet away from Individual #1, and were not observed to intervene.

Observations on 7/14/16 from 6:02 p.m. – 6:26 p.m. of the dinner meal in the facility's dining room revealed that Individuals #'s 1 – 6  ate their dinner with the contaminated silverware.

Interview on 7/14/16 at 7:05 p.m. with the house manager revealed that she did not observe Individual #1 contaminate the tableware because, in her words, "I was training (DCS A)."

Interview on 7/14/16 at 7:11 p.m. with DCS A revealed that he did not notice Individual #1 contaminate the tableware because, in his words, "I can't watch (Individual #1) and be trained at the same time."