F0880

E

Failure to Follow Hand Hygiene, Enhanced Barrier Precautions, and Oxygen Equipment Protocols

Columbia, Missouri Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

Surveyors identified deficiencies in the facility’s infection prevention and control practices related to hand hygiene, use of Enhanced Barrier Precautions (EBP), and management of oxygen equipment. Facility policies on handwashing and hand cleanser directed staff to cleanse hands between resident contacts and after contact with bodily fluids, but did not clearly address hand hygiene frequency or glove changes between dirty and clean tasks. The perineal care policy instructed staff to remove gloves and wash hands after care, but did not specify hand hygiene and glove changes between dirty and clean portions of the procedure. The EBP policy required use of gown and gloves for high-contact resident care activities, including dressing, bathing, transferring, hygiene, changing briefs, and toileting, for residents with MDRO risk or wounds. The oxygen equipment policy required tubing, masks, and cannulas to be replaced monthly and PRN, labeled with date and initials, and stored appropriately.

For one resident with severe cognitive impairment, incontinence, and care plan directions for EBP and oxygen use as needed, staff failed to follow hand hygiene and EBP requirements during perineal care. Observations showed the resident’s nasal cannula and oxygen tubing lying on the floor, with no storage bag attached to the concentrator. Staff entered the room, which had EBP signage requiring gown and gloves, but three aides did not wear gowns. One aide picked up oxygen tubing from the floor and placed it on the concentrator; another aide touched the bottom of the resident’s shoes and then placed the oxygen cannula into the resident’s nose with the same soiled gloves. During perineal care, the aide did not perform hand hygiene or change gloves between cleaning the perineal area and placing a clean brief, applying powder, touching the resident’s drawer, fastening the brief, and handling the mechanical lift sling and oxygen tubing. The aide then removed gloves and handed the call light to the resident without hand hygiene. Another aide placed a bag with a soiled brief on the floor, handled the resident’s personal items, and left the room without performing hand hygiene. Interviews with the aides revealed they were unaware the resident was on EBP, did not notice the door signage, and acknowledged missing hand hygiene and glove change opportunities.

For a second resident with moderate cognitive impairment, a wound, and a care plan requiring EBP with gown and gloves for high-contact care, staff again failed to follow EBP. The resident’s door displayed EBP signage instructing staff to wear a gown and gloves, but an aide entered to provide perineal care wearing gloves only and no gown. The resident reported having wounds on the buttocks. The aide later stated they did not know the resident had a wound and did not notice the EBP signage until after leaving the room. Facility leadership confirmed that signage is placed on doors for residents on precautions and that staff are educated to use gown, gloves, and mask for residents on EBP.

Surveyors also found deficiencies in oxygen equipment management for three residents. For the first resident, physician orders required monthly oxygen tubing changes on Sundays, but the treatment administration records lacked documentation that tubing was changed on the specified dates. The resident’s oxygen tubing was observed on the floor, undated, and without a storage bag on the concentrator. For a third resident, the MDS and physician orders did not indicate oxygen use or orders for tubing changes, yet the resident was observed in bed with a nasal cannula in place, undated tubing, and no storage bag on the concentrator. For a fourth resident, assessments and care plan indicated no routine oxygen use, but there was an order for PRN oxygen at two liters without an order for tubing replacement. This resident was observed wearing an undated nasal cannula, with no documentation of tubing changes in the treatment record and no storage bag on the concentrator. Interviews with nursing staff and administration confirmed that tubing should be labeled with the change date, documented in the TAR, changed if it had been on the floor, and stored in a bag when not in use, but there was no system in place to ensure these tasks were consistently completed.