Failure to Follow Infection Control Protocols for Enhanced Barrier Precautions and Oxygen Equipment
Penalty
Summary
Staff failed to adhere to infection prevention and control standards for two residents requiring enhanced precautions and respiratory care. For one resident with a history of extended spectrum beta lactamase (ESBL) resistance and colonization with a multidrug-resistant organism (MDRO), staff did not follow the facility's Enhanced Barrier Precautions (EBP) policy. The policy required staff to wear both gowns and gloves during high-contact care activities such as incontinence care. However, during an observed episode of incontinence care, two certified nursing assistants (CNAs) entered the resident's room, wore gloves but did not don gowns, despite clear signage and care plan instructions indicating the need for full EBP. Interviews with the CNAs, a private sitter, an LPN, the Director of Nursing (DON), and the Executive Director confirmed that staff were aware of the requirement but failed to comply during the observed care. In a separate incident involving another resident with chronic respiratory failure and COPD, staff did not properly handle and store oxygen equipment. The facility's policy required oxygen tubing to be changed if contaminated and to be stored safely when not in use. During observation, the resident's oxygen tubing and nasal cannula were found on the floor. A CNA subsequently picked up the tubing from the floor and reapplied it to the resident without replacing it. Interviews with the CNA, an LPN, the DON, and the Executive Director confirmed that the tubing should have been considered contaminated and replaced before use, and that proper storage (such as using a bag) was not implemented. Both deficiencies were directly observed and confirmed through staff interviews and review of facility policies and care plans. The failures involved not following established infection control protocols for residents at increased risk of infection, specifically regarding the use of PPE during high-contact care and the handling of respiratory equipment.