Failure to Follow Infection Control Protocols for Enhanced Barrier Precautions and Oxygen Tubing
Penalty
Summary
The facility failed to follow proper infection prevention and control practices in two separate instances. In the first case, a Certified Nursing Assistant (CNA) provided care to a resident with diagnoses including cardiomegaly, type 2 diabetes with neuropathy, and chronic mastoiditis, who was under Enhanced Barrier Precautions (EBP) due to a wound. Despite a physician's order and signage indicating EBP, the CNA did not wear a protective gown during high-contact care activities. The CNA stated she was unaware the resident remained on EBP, and the facility's policy required gown and glove use for such residents, which was not followed. In the second instance, a resident with hypoxia and chronic obstructive pulmonary disease was receiving continuous oxygen therapy via nasal cannula. Observation revealed that the oxygen tubing had not been changed in accordance with the facility's policy, which required weekly replacement. The Treatment Nurse acknowledged the tubing should have been changed, and the Director of Nursing and Administrator confirmed the policy was not followed. Both failures had the potential to result in cross-contamination among highly vulnerable residents.