Infection Control Lapses in Device Labeling, PPE Use, and Respiratory Equipment Storage
Penalty
Summary
The facility failed to follow infection prevention and control practices for three residents. For one resident with chronic respiratory failure, an incentive spirometer was observed on a shared shelf, unlabeled and not contained in a protective covering. Both the resident and a licensed nurse confirmed that the device was not labeled or bagged, despite facility policy requiring labeling and storage in a bag. The resident had a physician's order for use of the spirometer multiple times per week. Another resident with a history of cellulitis of the lower limb was on enhanced barrier precautions (EBP) due to a chronic wound. During personal care, a certified nursing assistant provided direct care without wearing the required personal protective equipment (PPE), even though signage at the room entrance indicated EBP and the care plan specified the use of gown and gloves for high-contact activities. The CNA acknowledged not wearing PPE, and the infection preventionist confirmed that PPE was required for such care. A third resident, admitted with chronic obstructive pulmonary disease, congestive heart failure, and sleep apnea, was observed with an oxygen concentrator and nasal cannula. The nasal cannula was left uncovered on top of the concentrator when not in use. Both the resident and a CNA confirmed the cannula was not bagged, and the director of staff development stated that respiratory tubing should be placed in an antimicrobial bag when not in use to prevent contamination. Facility policy also required safe storage of oxygen administration equipment.