Infection Control Deficiencies in PPE Use, Nebulizer Equipment Handling, and Linen Transport
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's infection prevention and control program. For a resident with an indwelling urinary catheter who required staff assistance for transfers, toileting, and catheter care, staff failed to consistently implement Enhanced Barrier Precautions (EBP) as required. Observations revealed that staff did not always wear gowns and gloves during high-contact care activities such as transferring and catheter care, despite clear signage and policy requirements. Staff interviews indicated a lack of understanding regarding when PPE was necessary, with some staff believing gowns and gloves were only needed for toileting or catheter care, not for transfers. Additionally, staff were observed reusing gowns or not donning PPE at all during resident care, and the resident’s catheter bag was placed on the floor without a barrier, contrary to infection control expectations. Further deficiencies were observed in the handling and storage of nebulizer equipment for three residents. Nebulizer masks and tubing were found lying uncovered directly on bedside tables or nightstands, with liquid visible in the medication reservoirs. Facility policy required that nebulizer equipment be rinsed after each use, washed daily, and stored on a clean barrier, but these procedures were not followed. Staff interviews confirmed that the expected cleaning and storage protocols were not consistently implemented, and the equipment was not replaced or stored as per policy. Additionally, the facility failed to ensure that clean linen was protected during transport. One of two clean linen carts used for distributing linens lacked a suitable protective cover, leaving the ends open and the linen exposed. The cover in use was made of fabric, was not cleanable, and was not being machine washed. Both the infection preventionist and environmental services director acknowledged that the cover did not adequately protect the linen from contamination, which was inconsistent with the facility’s policy requiring clean linen to be protected from dust and soiling during transport and storage.