Failure to Notify Visitors of Influenza Outbreak and Properly Store Nebulizer Masks
Penalty
Summary
The facility failed to consistently implement its infection prevention and control program during an influenza outbreak and in the handling of nebulizer equipment. During an initial tour, surveyors observed that all staff in resident care areas were wearing masks and staff reported this was required due to a flu outbreak that began several days earlier, with 21 residents testing positive. However, in the lobby there was no signage notifying visitors of the outbreak or recommending PPE such as masks, and the receptionist did not provide any information or instructions about the outbreak. Two family members who visited residents on multiple occasions reported they had not been notified of the flu outbreak, had not been offered masks, and only became aware of the situation by seeing staff wearing masks. The Infection Preventionist later confirmed that while resident representatives were notified of the outbreak by telephone, the facility did not encourage mask use for visitors and did not post signage to notify visitors or recommend/encourage mask use, contrary to the facility’s infection control policy requiring visitor education, use of isolation signs, and passive screening via posted signs. Surveyors also observed improper storage of nebulizer masks on two units. On the 300 unit, an uncovered nebulizer mask was seen on a resident’s dresser in front of the television, and on the 100 unit, another uncovered nebulizer mask was observed on a circular table in a resident’s room. Photographic evidence was obtained. The Infection Preventionist, upon reviewing the photos, stated that nebulizer items should be stored in a bag and that all nurses had been instructed on this practice. This practice was inconsistent with the facility’s written policy on oxygen administration, which requires delivery devices to be kept covered when not in use, and with the infection prevention and control policy that all staff follow procedures designed to prevent the development and transmission of communicable diseases and infections.
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