Failure to Follow Enhanced Barrier Precautions and Sanitary Storage of Respiratory Equipment
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, including Enhanced Barrier Precautions (EBP), during urinary catheter care and bathing. One resident with metabolic encephalopathy, mild protein calorie malnutrition, a stage 3 sacral pressure ulcer, dementia, chronic kidney disease, benign prostatic hyperplasia with urinary retention, and an indwelling urinary catheter and PEG tube had an EBP sign posted on the room door. During observation of a bed bath and catheter care, two CNAs entered the room and provided care without donning gowns, despite facility guidance that gowns and gloves are to be used for high-contact care activities such as bathing and device care for residents with indwelling devices and wounds. One CNA performed catheter care and a bed bath without a gown, and the other washed the resident’s face without a gown. During the same bathing episode, the CNA providing catheter care used improper bathing technique that did not follow infection control practices. After placing soap into a washbasin, the CNA cleaned the resident’s penis with a washcloth and then placed the washcloth back into the soapy water. The CNA then retrieved the same washcloth and used it to wipe the resident’s buttocks, legs, and over an open blister on the leg, repeatedly returning the washcloth to the same basin of soapy water. The CNA continued to wash the resident’s lower legs with the same washcloth that had already been used on the genital and perineal areas and over the open blister. In a subsequent interview, the CNA acknowledged not using a gown and confirmed using the same washcloth after cleaning the resident’s penis. The facility also failed to store respiratory equipment in a sanitary manner for two additional residents. For one resident with a history including cerebrovascular accident, dysphagia, acute respiratory failure, protein calorie malnutrition, hypertension, and muscle wasting, a nebulizer mask was observed lying uncovered on a bedside table, and a Yankauer oral suction instrument was observed sitting uncovered on the suction machine, contrary to facility policy requiring such items to be stored in bags. For another resident with interstitial pulmonary disease, pulmonary fibrosis, chronic pulmonary edema, and mild intermittent asthma, an oxygen concentrator with humidifying water was present in the room, and the oxygen tubing attached to the concentrator was observed not stored in a bag and lying on the floor on multiple observations when the resident was not using oxygen. The DON later confirmed that the oxygen tubing should have been stored in a bag and was not stored correctly.
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