Infection Control Failures in Oxygen Equipment, Hand Hygiene, PPE, and Laundry Handling
Penalty
Summary
The facility failed to properly store and handle oxygen equipment for a resident receiving oxygen therapy. During an observation, a staff member removed the resident's nasal cannula and placed it on the floor, then later picked it up and stored it on the oxygen concentrator without cleaning the equipment or the machine. Facility leadership confirmed that oxygen tubing should be stored in a clean bag and the concentrator should be wiped down before replacing equipment, and acknowledged that the observed actions did not follow protocol. Staff failed to perform hand hygiene during dining services, as observed with an activity assistant who repeatedly touched her eyeglasses, handled linens, food trays, and other items without performing hand hygiene between tasks. The dietary manager and infection preventionist both confirmed that hand hygiene should be performed after touching oneself or personal items and before serving food, and that the observed practices did not meet expectations or policy. The facility also did not ensure proper use of personal protective equipment (PPE) for residents on enhanced barrier precautions (EBP). A certified nursing assistant provided catheter care to a resident on EBP without wearing a gown and did not perform hand hygiene with every glove change. Additionally, laundry services were observed to have an open linen cart in the hallway with dirty hangers placed on top, and staff did not perform hand hygiene between handling dirty and clean items. Facility leadership confirmed that clean and dirty items should not be stored together and that the linen cart should remain closed except when in use in a resident room.