Infection Control Lapses in Device Management, EBP Implementation, and Hand Hygiene
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices within the facility. One deficiency involved a resident's CPAP mask, which was not stored in a microbial bag as required by facility policy. Instead, the mask was left on top of the CPAP machine, exposing it to potential contamination. The Director of Nursing and Infection Preventionist confirmed that the mask should have been stored in a microbial bag to prevent infection, as per standard practice. Another deficiency was observed regarding the lack of Enhanced Barrier Precautions (EBP) for several residents with invasive medical devices or wounds. Residents with urinary catheters, gastrostomy tubes, suprapubic catheters, and pressure ulcers did not have EBP signage posted, nor was personal protective equipment (PPE) available inside or outside their rooms. Medical records for these residents did not document EBP implementation, despite facility policy requiring EBP for residents with such conditions. The Infection Preventionist confirmed that EBP, including gown and glove use during high-contact care, should have been in place for these residents. Additional deficiencies included the failure to label and date medical equipment such as oxygen tubing, feeding tubes, and IV bags and tubing for several residents. Staff were observed not performing hand hygiene between resident contacts in the dining room and during medication administration. Both a CNA and a licensed nurse admitted to forgetting to perform hand hygiene, which was confirmed as a requirement by the facility's policies. These lapses in infection control practices were directly observed and verified by staff interviews.