Failure to Maintain Infection Control: Improper Oxygen Tubing Storage and Hand Hygiene Lapses
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices involving three residents. For one resident requiring continuous oxygen therapy due to chronic obstructive pulmonary disease and coronary artery disease, the oxygen tubing was observed uncovered and lying on the floor, both at the oxygen machine and portable tank. The tubing was not stored in a protective bag as required, and staff confirmed that such storage was necessary to prevent contamination. The resident was unaware that the tubing was not connected to the machine, and staff acknowledged the tubing was contaminated and needed replacement. Additionally, two certified nursing assistants (CNAs) were observed distributing meal trays to residents without performing hand hygiene between residents. One CNA provided a meal tray and set up the meal for a resident, then immediately proceeded to the next resident's room and handled another meal tray without sanitizing their hands. The second CNA followed a similar process, setting up a meal tray for a resident and then moving to another room without hand hygiene. Both CNAs acknowledged during interviews that hand sanitization was required between residents to prevent infection, and the facility's policy confirmed this expectation. The facility's own infection control policies, including those on standard precautions and hand hygiene, were not followed in these instances. The policies require hand hygiene before and after resident contact and proper handling and storage of resident-care equipment to prevent contamination. These failures were directly observed and confirmed by staff interviews and record reviews, demonstrating a breakdown in adherence to established infection control protocols.