Failure to Follow Infection Control Protocols for Oxygen Equipment and Personal Toiletries
Penalty
Summary
The facility failed to implement infection control guidelines in two key areas. First, a resident with chronic obstructive pulmonary disease (COPD) and diabetes mellitus was observed using a nasal cannula (NC) for oxygen therapy that had not been changed weekly as required. The NC bag was dated nearly a month prior to the observation, and both the Licensed Vocational Nurse and the Infection Preventionist Nurse confirmed that the NC should be changed weekly to prevent bacterial accumulation, in accordance with facility policy. The resident's medical records indicated an active order for oxygen via NC as needed for respiratory symptoms and comfort. Second, the facility did not ensure that personal toiletry items were properly labeled and stored for several residents sharing a restroom. During an observation, an unlabeled, opened bottle of moisturizing shampoo and body wash was found on the window sill of a shared restroom accessible by six residents with varying degrees of cognitive impairment and assistance needs. The Certified Nursing Assistant and Infection Preventionist Nurse both stated that personal toiletries should be labeled and stored at the resident's bedside or in their drawer to prevent cross-contamination, as outlined in the facility's policies on personal hygiene items and infection control. These failures were identified through observation, interviews with staff, and review of facility policies and resident records. The deficiencies had the potential to contribute to the spread of infection within the facility, as personal care items were not managed according to established infection prevention protocols.