Widespread Infection Control Lapses in Equipment Handling and Storage
Penalty
Summary
Multiple infection prevention and control deficiencies were observed throughout the facility, involving improper handling and storage of medical equipment and supplies. For example, a resident's bedside table contained an opened plastic bag with a gastrostomy (GT) syringe, and the same resident's urinary catheter tubing was positioned above the bladder and kinked, which was confirmed by a licensed vocational nurse (LVN) as incorrect. In another room, an opened and unlabeled GT syringe was found on a bedside table shared by two residents on isolation precautions, and an opened, unlabeled plastic bag with an enteral feeding tube was found touching an opened package of ointment on another resident's table. Additionally, a used spirometer mouthpiece with a dried yellowish substance was found touching the inside of a wash basin, and a dirty plastic garbage bag was observed touching a box of clean gloves on a resident's bed. Dakin's solution was also stored in the treatment cart without being cleaned after use during a wound dressing change. Further deficiencies included improper storage of nasal cannulas for two residents receiving oxygen therapy, as the cannulas were not in use and were left on surfaces such as a bed rail and a humidifier, which was acknowledged as an infection control issue by staff and the facility's infection preventionist. A nurse was observed wearing an N95 mask below her nose and mouth while preparing medications, despite a facility-wide requirement for proper mask use due to an influenza outbreak. Additionally, a resident's Foley catheter drainage bag was found on the floor, and staff confirmed it should have been anchored to the bed frame and not left on the floor. Enteral feeding tubes for three residents were not dated as required, and the filters on an oxygen concentrator for another resident were found to be dirty, contrary to facility policy and manufacturer recommendations for weekly cleaning. Finally, a nurse was observed failing to sanitize a stethoscope after use on a resident's gastrostomy tube before placing it back in the medication cart. This was confirmed by both the nurse and the Director of Nursing, who stated that the stethoscope should have been disinfected between uses. Facility policies and procedures reviewed during the survey supported the need for proper cleaning and disinfection of reusable medical equipment and supplies, as well as correct storage and labeling practices to prevent the transmission and spread of infection.