Failure to Follow Infection Control Practices and Proper Handling of Oxygen Equipment
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices in several instances involving two residents. For one resident with multiple diagnoses, including pressure-induced deep tissue damage and congestive heart failure, staff did not follow Enhanced Barrier Precautions (EBP) as required. Despite signage indicating the need for gloves and gowns during high-contact care activities, a certified nurse assistant was observed providing face hygiene care without wearing any personal protective equipment (PPE). Both the Infection Preventionist Nurse and the Director of Nursing confirmed that PPE should have been used for residents on isolation precautions. Additionally, the facility did not ensure that nasal cannula (NC) tubing used for oxygen delivery was kept off the floor for two residents. One resident, who was dependent for personal hygiene and had an order for continuous oxygen, was observed with their NC touching the floor while in bed. The attending licensed vocational nurse acknowledged that this was inappropriate for infection control. Similarly, another resident with intact cognition and an as-needed oxygen order was found with their NC tubing on the floor. The nurse present and the Director of Nursing both recognized this as an infection control risk and stated that the tubing should be replaced. A review of facility policies indicated that oxygen delivery devices must be kept clean and changed as needed, and that PPE is required during certain care activities to prevent exposure to bodily fluids. The facility's in-service training also emphasized the importance of proper storage of personal belongings to prevent contamination. These observations and interviews demonstrate lapses in adherence to established infection control protocols, specifically regarding the use of PPE and the handling of oxygen delivery equipment.