Failure to Maintain Infection Control in Oxygen Therapy and Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for two of twenty sampled residents. For one resident with chronic obstructive pulmonary disease (COPD), repeated observations showed that the nasal cannula and oxygen tubing were left lying directly on the floor, including under the bed and under the bed's wheel, when not in use. This occurred despite facility policy requiring oxygen devices to be changed when soiled or dirty and to be stored properly when not in use. Multiple staff, including the Assistant Director of Nursing, Director of Nursing, and Corporate Divisional Nurse, confirmed that oxygen tubing should not be on the floor and that this practice constitutes an infection control issue. For another resident with diagnoses including seizures and migraines, a registered nurse was observed administering medications in a manner inconsistent with infection control protocols. The nurse punched pills out of medication cards and dispensed pills from bottles directly into his hand before placing them into medication cups, rather than placing them directly into the cup or using the bottle lid as required by facility policy. The nurse acknowledged this deviation from protocol, and both the Infection Preventionist and Director of Nursing confirmed that staff are expected to avoid direct hand contact with medications during administration. These observed failures to follow established infection control procedures for oxygen therapy and medication administration placed residents at risk for the transmission and spread of infections. The deficiencies were confirmed through staff interviews, record reviews, and direct observation, and were not in accordance with the facility's own policies.