Failure to Implement Infection Control Practices for Oxygen Therapy, Contact Precautions, and Linen Storage
Penalty
Summary
The facility failed to implement proper infection prevention and control practices in several instances involving both residents and staff. One resident with chronic respiratory conditions, including COPD, pneumonia, and acute respiratory failure, was observed with a nasal cannula that was discolored and wrapped around a bed side rail. The oxygen concentrator was set at 5 LPM without a humidifier, despite a physician's order specifying 2 LPM PRN to maintain oxygen saturation above 92%. Staff did not follow the physician's order, and the nasal cannula tubing was not stored in a sanitary manner, as required by facility policy. The tubing was not replaced promptly, and the oxygen was administered at a higher rate than ordered, with no documentation of a change in the resident's condition or a new order to justify the increase. Another deficiency was observed in the facility's laundry area, where a staff member's personal belongings, including a lunch bag and backpack, were placed next to clean linen on a linen cart. This practice was acknowledged by both the staff member and the maintenance supervisor as inappropriate, as it could lead to contamination of clean linen. The infection preventionist confirmed that personal belongings should not be stored in the clean laundry room, and the facility's policies require separate storage for clean linen and personal items to prevent the spread of infection. Additionally, a certified nursing assistant failed to don a gown while providing care to a resident on contact precautions for a multidrug-resistant organism in a stage four pressure ulcer. The CNA stated she was unaware of the contact precautions signage and did not wear a gown while in the resident's room, despite touching potentially contaminated surfaces. Facility policy and interviews with nursing and infection prevention staff confirmed that a gown should have been worn to prevent the spread of infection. These failures were observed and confirmed through interviews and record reviews, demonstrating lapses in adherence to established infection control protocols.