Failure to Follow Infection Control Protocols for Oxygen Therapy and Glucometer Disinfection
Penalty
Summary
Nursing staff failed to implement proper infection prevention and control practices for three residents. For one resident receiving oxygen therapy, the nasal cannula was not changed every seven days as required by both physician order and facility policy. The cannula in use was labeled with another resident's name and an outdated date, and an additional cannula attached to a portable oxygen tank was not dated or stored in a plastic bag, leaving it exposed to the environment. Staff interviews confirmed uncertainty about the required frequency for changing the cannula and improper storage practices, despite clear facility policies mandating weekly changes, labeling, and sanitary storage. Additionally, two residents who required blood glucose monitoring were exposed to improper disinfection practices with a shared glucometer. A nurse was observed wiping the glucometer with a Sani-Cloth disposable wipe but did not adhere to the manufacturer's specified contact time, which requires the surface to remain wet for two minutes to ensure effective disinfection. The nurse was unaware of the meaning of 'contact time' and did not follow the instructions on the wipe label. The infection preventionist and DON both acknowledged that staff were expected to follow the manufacturer's instructions for disinfection but confirmed that the observed practice did not meet these requirements. Facility policy for both oxygen therapy and blood glucose monitoring clearly outlined the necessary infection control steps, including equipment change intervals, labeling, storage, and disinfection procedures. However, observations and staff interviews revealed that these protocols were not consistently followed, resulting in a failure to prevent potential cross-contamination and infection among the affected residents.