Infection Control Lapses in Hand Hygiene, IV Equipment, and Respiratory Equipment Storage
Penalty
Summary
Staff failed to consistently implement infection prevention and control practices during the care of residents requiring specialized medical equipment and procedures. During PEG tube care for a resident with a history of gastronomy status and dysphagia, a registered nurse changed gloves multiple times but did not perform hand hygiene between glove changes, contrary to facility policy and staff interviews that emphasized the importance of hand hygiene at each glove change. The resident’s care plan required monitoring for infection and providing local care to the tube site, but the observed practice did not align with these requirements. Additionally, multiple observations revealed that empty antibiotic IV bags with uncapped tubing were left hanging on IV poles in a resident's room over several facility tours. According to the DON and LPN interviews, IV bags and tubing should be discarded immediately after use, and tubing ports should be capped when not in use. The facility’s policy also requires aseptic technique and proper handling of IV equipment to prevent infection. Further deficiencies were observed in the storage of respiratory equipment. In one resident’s room, a nebulizer machine with tubing and mask was left uncovered on a chair next to a rat trap, and this condition persisted across multiple observations. Staff interviews confirmed that respiratory supplies should be stored in a labeled, closed bag to prevent contamination, and facility policy classifies such equipment as semi-critical, requiring cleaning, disinfection, and proper storage. These lapses in infection control practices were observed while the facility housed 257 residents.