Infection Control Failures in Respiratory Care, Catheter Care, Laundry Handling, and Water Management
Penalty
Summary
The facility failed to implement adequate infection prevention and control measures in several areas related to respiratory care, urinary catheter care, laundry handling, and water system management. For one resident requiring supplemental oxygen, the oxygen tubing and nasal cannula were observed not labeled with the date of administration and not stored in a bag when not in use, as required by facility policy. The equipment was left exposed, wrapped around a bed bar, and connected to a humidifier, also undated. Staff interviews confirmed that the equipment should have been dated and bagged to prevent contamination, but these procedures were not followed. Another resident with a BIPAP machine and a supra-pubic catheter did not have a physician order or care plan focus for BIPAP therapy, and the BIPAP mask and hose were found with visible moisture, stored in an open drawer and not bagged. During catheter care, staff wore gloves but did not use an isolation gown as required by the resident's care plan and physician orders for enhanced barrier precautions (EBP). The resident confirmed that staff did not consistently use gowns during catheter care, and staff interviews revealed a lack of awareness regarding the EBP requirement for catheter care. Additionally, laundry was observed being delivered to resident rooms uncovered, contrary to facility practice of returning clean clothes in individual bags. The housekeeping supervisor acknowledged the incident. Regarding water management, the maintenance supervisor reported the absence of a facility water flow map, lack of documentation for maintenance activities, and unawareness of the water management or legionella prevention plans, despite facility policies requiring such programs and documentation.