Failure to Follow Infection Control Practices for Oxygen Equipment and Linen Handling
Penalty
Summary
The facility failed to follow safe infection control practices and maintain a sanitary environment in several instances. For one resident with chronic respiratory failure, an oxygen nasal cannula tubing in use was found to be unlabeled and undated, despite a physician order requiring the cannula to be changed every Sunday and as needed. A Licensed Vocational Nurse confirmed the tubing was not labeled as required, and the Director of Nursing acknowledged that the facility's policy, which mandates weekly changes and labeling, was not followed. Similarly, another resident with acute respiratory failure and heart failure was observed using a nasal cannula oxygen tubing that was also not labeled or dated. Both a Licensed Vocational Nurse and a Registered Nurse were unable to confirm when the tubing was last changed, and the Director of Nursing again confirmed that the facility's policy was not adhered to in this case. Additionally, a janitor removed multiple pillows from trash containers and placed them on a handrail near the laundry room, believing they were mistakenly discarded. The Environmental Services Director and Infection Preventionist both stated that items removed from trash should not be reused or placed in common areas due to contamination risks. The facility's infection prevention and control policy requires contaminated reusable items to be bagged and labeled for processing, and linens to be handled in a way that prevents the spread of infection. These actions were not followed, as the pillows were left exposed in a high-traffic area after being removed from trash bins containing dirty linen and waste from resident rooms.