Failure to Implement Infection Control Practices for Medical Devices and Equipment
Penalty
Summary
The facility failed to implement and maintain proper infection prevention and control practices for multiple residents. One resident with a gastrostomy tube was not placed on enhanced barrier precautions (EBP) as required by facility policy, despite the presence of an indwelling medical device. The room lacked EBP signage and a PPE supply cart, and the Infection Prevention Nurse confirmed that these should have been in place to reduce the risk of bacterial transmission. The facility's policy indicated that EBP is necessary for residents with devices such as feeding tubes, but this was not followed for the resident in question. Another deficiency was observed with a resident receiving oxygen therapy. The oxygen tubing was not labeled with the date it was last changed, and staff could not confirm when it had been replaced. Facility policy and staff interviews indicated that oxygen tubing should be changed and labeled at least weekly to prevent infection, but this was not done. In a separate instance, a different resident's oxygen tubing was not replaced weekly as required, with the tubing in use for more than three weeks, contrary to the facility's infection control protocol. Additionally, a resident's urinal was found at the bedside without a resident identifier label. Staff confirmed the urinal was not labeled, and the DON stated that labeling is necessary to prevent cross-contamination. However, the Director of Medical Records noted that there was no specific policy addressing urinal labeling. The facility's general infection prevention and control policy requires measures to prevent the development and transmission of communicable diseases, but these specific practices were not consistently implemented.