Infection Control Failures in Hand Hygiene and Oxygen Equipment Storage
Penalty
Summary
Surveyors observed multiple failures in infection prevention and control practices involving two residents. In one instance, a Licensed Vocational Nurse (LVN) was seen exiting a resident's room after performing a wound dressing change, carrying the soiled dressing in her bare hands. The LVN disposed of the dressing in a trash can outside the room and then moved the wound cart without performing hand hygiene. Interviews with the LVN, Director of Nursing (DON), Director of Staff Development (DSD), and Infection Preventionist (IP) confirmed that this action did not follow facility policy or infection control protocols, as hand hygiene should have been performed after handling soiled dressings to prevent cross contamination. Additionally, the same resident did not have a storage bag available for their nasal cannula (NC) in the room. Observations and interviews with the DON, DSD, and IP confirmed that a storage bag should have been present and used to store the NC when not in use, as per facility policy and manufacturer recommendations. The absence of a storage bag meant the NC could have been exposed to unclean surfaces, increasing the risk of contamination. A separate observation found another resident's oxygen NC tubing lying unbagged on a bedside table next to used tissues and a trash can. Staff interviews confirmed that the NC should have been stored in a designated bag when not in use, and that the tubing is changed weekly and should be labeled. The IP and DON both validated that the observed practice did not align with facility policy, and that the NC was at risk of contamination due to improper storage. Facility policies and professional references reviewed by surveyors supported the expectation for proper storage and handling of respiratory equipment to prevent infection.