Failure to Follow Infection Control Policies for CPAP Cleaning and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow the facility's policy for cleaning Continuous Positive Air Pressure (CPAP) equipment for two residents diagnosed with Obstructive Sleep Apnea. Observations over several days revealed that one resident's CPAP mask had dried brown specks and an empty water chamber, while another resident's CPAP mask had a heavy layer of dried white coating and a partially filled water chamber. There was no documentation on the Treatment Administration Record (TAR) or Medication Administration Record (MAR) indicating that the CPAP equipment was being cleaned as required by facility policy. The Director of Nursing confirmed the lack of documentation for both residents. Additionally, the facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a diagnosis of MRSA, peripheral vascular disease with venous ulcers, and a suprapubic catheter. The resident's care plan indicated the need for EBP during high-contact care activities, such as transfers and catheter care. Despite signage indicating EBP requirements, a Medication Aide was observed transferring the resident and handling the catheter bag without wearing a gown or gloves, contrary to facility policy. Interviews with the Director of Nursing confirmed that staff were expected to wear appropriate personal protective equipment (PPE) during high-contact care activities for residents on EBP. The observed failures to follow cleaning protocols for CPAP equipment and to implement EBP during resident care represent lapses in the facility's infection prevention and control program.