Infection Control Lapses in Catheter Care, Nebulizer Equipment, and PPE Use
Penalty
Summary
The facility failed to maintain safe and sanitary care practices for its residents, as evidenced by multiple infection control lapses. One resident with a history of sepsis, urinary calculus, and kidney infections was observed with an uncovered nephrostomy bag hanging from the bedrail and an uncovered urinary catheter bag lying on the floor. A licensed nurse confirmed that catheter bags should not touch the ground for infection control reasons, and the facility's policy also requires catheter tubing and drainage bags to be kept off the floor. Another resident, diagnosed with dementia, COPD, and congestive heart failure, was found to have nebulizer face mask tubing labeled with a date more than seven weeks prior, despite facility policy and staff statements that such equipment should be changed weekly. Both the infection preventionist and the DON confirmed that the tubing should be changed every seven days to prevent respiratory infections, but this was not done in accordance with the policy. Additionally, staff failed to adhere to required personal protective equipment (PPE) protocols for a resident on contact isolation precautions due to VRE and possible C. difficile infection. Despite signage indicating that gloves and gowns must be worn upon entering the room, staff members, including activities staff and a CNA, entered the room without the required PPE. The infection preventionist confirmed that the facility's practice was to wear PPE only when directly caring for the infected resident, which contradicted both facility policy and CDC guidance requiring PPE upon every entry into the room.