Infection Control Failures in Hand Hygiene, PPE Use, and Respiratory Equipment Maintenance
Penalty
Summary
Staff failed to comply with infection prevention and control guidelines, as evidenced by multiple observations of a nursing assistant not performing hand hygiene during meal tray delivery. The staff member was seen handling meal trays, touching residents’ personal items and silverware, and assisting with resident care activities without performing hand hygiene before or after these tasks. The staff member also did not demonstrate knowledge of when hand hygiene should be performed during meal pass, and admitted to not performing hand hygiene while passing lunch trays. In another instance, a staff member did not use appropriate personal protective equipment (PPE) when providing care to a resident on enhanced based precautions (EBP) due to an indwelling device. The staff member only wore gloves, despite facility policy and signage indicating the need for additional PPE such as gowns, masks, and eye protection during high-contact care activities. The staff member was unable to explain the purpose of EBP or when it should be implemented, and reported only using gloves when assisting the resident with toileting. Additionally, the facility failed to ensure proper storage and maintenance of oxygen and nebulizer tubing for a resident. Observations revealed that oxygen tubing and a nasal cannula were left touching the floor or stored inappropriately, and nebulizer equipment appeared dirty, was not dated, and was not stored in a plastic bag. Staff interviews indicated inconsistent practices regarding labeling, dating, and storing respiratory equipment, and documentation of tubing changes was not found in the treatment administration record.