Failure to Date Oxygen Tubing, Adhere to Enhanced Barrier Precautions, and Perform Hand Hygiene
Penalty
Summary
The facility failed to properly date and track oxygen tubing for a resident with multiple respiratory diagnoses, including dyspnea, congestive heart failure, obstructive sleep apnea, and acute and chronic respiratory failure. Observations over several days revealed that the resident's oxygen tubing and nasal cannula were not marked with the date they were placed, and interviews with nursing staff and the DON confirmed that there was no method in place for tracking the change of respiratory supplies, despite a policy that tubing should be changed weekly. Additionally, the facility did not ensure that staff followed Enhanced Barrier Precautions (EBP) for a resident with a gastrostomy tube who required assistance with all activities of daily living. Despite signage indicating the need for gown and glove use during high-contact care activities, a hospice nurse aide was observed providing toileting, hygiene, and transfer assistance without donning a gown, in direct violation of the posted EBP requirements. This was confirmed by both the aide and the facility wound nurse during interviews. The facility also failed to enforce proper hand hygiene practices during medication administration. An observation showed a medication aide preparing and administering eye drops to a resident without performing hand hygiene prior to donning gloves, contrary to facility policy. The aide confirmed in an interview that hand hygiene was not performed before gloving, as required.