Failure to Follow Enhanced Barrier Precautions and Proper Oxygen Tubing Storage
Penalty
Summary
The facility failed to ensure staff adhered to Enhanced Barrier Precautions (EBP) and proper use of Personal Protective Equipment (PPE) during resident care. Specifically, an LPN was observed administering a water flush through a resident's PEG tube without donning a gown, despite clear signage and availability of PPE outside the resident's room. The resident involved had multiple diagnoses, including convulsions, dementia, failure to thrive, dysphagia, and was cognitively impaired. The facility's policy required the use of gown and gloves for high-contact care activities involving medical devices, which was not followed in this instance. Both the LPN and the DON acknowledged the lapse in protocol during interviews. Additionally, the facility did not ensure proper storage of oxygen tubing for three residents receiving oxygen therapy. Observations revealed that nasal cannula tubing was left exposed on chairs or wheelchairs and not stored in plastic bags when not in use, as required by facility policy. Staff interviews confirmed awareness of the correct procedure, and the DON stated that oxygen tubing should be stored in a plastic bag when not in use. The residents involved had diagnoses such as obstructive sleep apnea, chronic respiratory failure, asthma, and other chronic conditions, and were cognitively intact according to their assessments.