Uncertified Staff Use, Inadequate Isolation Practices, and Non-Specific Oxygen Orders
Penalty
Summary
The deficiency involves the facility’s administration, including the Administrator (ADM), Infection Prevention Coordinator (IPC), and Interim Director of Nursing (IDON), failing to ensure staff were properly trained and certified before providing care, failing to implement appropriate infection control practices, and failing to obtain specific medical orders for oxygen and related respiratory devices. Surveyors’ review of personnel files showed that three nurse aides in training (NAITs) had start dates as nurse aides but no evidence of certification as CNAs in their files. The ADM initially reported that these NAITs were certified on specific dates, but the personnel records did not contain proof of certification. The ADM later confirmed that two of the NAITs were still working in a nurse aide capacity without certification and that the third NAIT, who had signed a non-certified nursing aide job description, was being used as transport staff without a transport job description in the file. The deficiency also includes failures in infection control practices for a resident on contact plus droplet precautions and modified protection environment precautions. The facility’s policy referred to CDC guidance, which recommends clear signage outside rooms indicating the type of precautions and required PPE. Observations showed that a resident on chemotherapy had a Modified Protection Environment sign at the doorway listing restrictions such as no plants, flowers, or animal visits and strict hand hygiene, but the sign did not indicate the type of precautions or PPE to be used. The IPC confirmed that an additional sign for contact plus droplet precautions should have been posted but was not initially visible. Later, a contact plus droplet sign was observed with instructions for staff to clean hands and wear gown, gloves, mask, and eye protection. Despite this, the resident was observed in the therapy room without a mask while receiving assistance with hygiene and drinking, with multiple staff and other residents present and no staff wearing gowns or face shields and no other residents wearing PPE. The IPC stated that the resident was only required to wear a mask as tolerated, that the family had requested therapy in the room due to COVID exposure, and that the facility could not force the resident to stay in the room or wear a mask. Further, the facility did not obtain or follow specific medical orders required for oxygen use and CPAP therapy. Record review showed that some residents had oxygen orders written with broad ranges (e.g., one to six liters per minute or one to five liters per minute via nasal cannula) without specifying the exact flow rate or clarifying whether oxygen was to be continuous or PRN. One resident using oxygen and another using a CPAP machine had no corresponding physician orders in the record, despite documentation from a hospital discharge indicating that CPAP use was ordered for a resident with acute and chronic respiratory failure with hypoxia. During interview, the IDON confirmed that the oxygen orders lacked specific flow rates and that residents using oxygen and CPAP should have orders but did not. The IDON also stated that orders did not need to specify the amount of oxygen because nurses would use their judgment to keep oxygen saturation above 90, reflecting a failure to recognize that specific orders are required for oxygen use.
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