Failure to Follow Infection Control and Physician Orders in Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents by not adhering to infection control standards and physician orders. For one resident with a tracheostomy, a nurse did not remove soiled gloves, perform hand hygiene, or don new sterile gloves during tracheostomy care. The nurse used the same gloves throughout the procedure, including when handling sterile supplies and performing cleaning around the tracheostomy site. This was observed by surveyors and confirmed in interviews with the nurse, the Infection Preventionist, the DON, and the Administrator, all of whom stated that proper infection control practices were not followed. Additionally, the same resident had a physician's order for daily tracheostomy tie changes, but during observed care, the nurse failed to change the tracheostomy ties. The ties were noted to have a dried yellow substance near the tracheostomy site. The nurse acknowledged forgetting to change the ties during the procedure, and both the DON and Administrator confirmed that the physician's order was not followed. For another resident, the facility failed to obtain a physician's order for the use of a CPAP machine, despite the resident bringing her personal CPAP from the hospital and using it nightly for sleep apnea. The admissions nurse was unaware of the CPAP use, and the device was not documented in the resident's orders or coded in the MDS. Staff interviews confirmed the resident's nightly use of the CPAP, and the unit manager and Administrator acknowledged that a physician's order should have been in place for its use.