Failure to Follow Infection Control Policies for Enhanced Barrier Precautions and Oxygen Tubing
Penalty
Summary
Staff failed to follow infection control policies for three residents. For one resident on Enhanced Barrier Precautions (EBP) due to IV therapy and risk of infection, a CNA provided incontinent care wearing only gloves and not a gown, as required by posted signage and facility policy. The CNA did not change gloves or perform hand hygiene after caring for this resident and proceeded to provide care to another resident, touching the environment and the resident without proper infection control measures. Both the CNA and other staff confirmed knowledge of the EBP requirements, which include wearing gowns and gloves for high-contact care and changing gloves and performing hand hygiene between residents. Additionally, a resident using oxygen therapy had a nasal cannula that was not labeled with a start date, contrary to facility policy and staff expectations that oxygen tubing be labeled and changed weekly to prevent bacterial accumulation. The nurse was unable to determine how long the cannula had been in use. These lapses were observed and confirmed through staff interviews and record reviews, demonstrating a failure to implement and follow established infection prevention and control protocols.