Improper Oxygen Equipment Storage and Hand Hygiene Failures During Medication Administration
Penalty
Summary
The deficiency involves failures in infection prevention and control related to oxygen equipment storage and hand hygiene during medication administration. One resident with acute and chronic respiratory failure with hypoxia, pulmonary hypertension, chronic pulmonary embolism, and dependence on supplemental oxygen had a physician’s order for BiPAP with oxygen and oxygen via nasal cannula, and a care plan addressing risk of respiratory complications and the need for oxygen as ordered. Surveyors observed this resident’s portable oxygen concentrator lying directly on the floor of the room on multiple occasions, including after a CNA removed it to be filled and then returned it to the floor uncovered. Another CNA stated that portable oxygen equipment and tubing should not be placed on the floor and should be stored behind the wheelchair or in the oxygen storage room, and the DON stated her expectation that oxygen delivery devices not be stored on the floor because this could be an accident hazard or lead to respiratory infection. Additional deficiencies were identified in hand hygiene and technique during medication administration, including topical eye medication. One LPN was observed leaving a resident’s room without sanitizing her hands before or after administering medications and confirmed she should have sanitized between residents. Another LPN prepared and administered medications to a resident without sanitizing his hands before or after administration, and later applied eye drops to a different resident using an ungloved hand to hold the eyelid open, again without performing hand hygiene afterward. This LPN acknowledged he should have sanitized his hands after touching each resident and administering medications. The DON stated her expectation that staff sanitize or wash their hands before and after medication administration, after touching a resident, or after touching environmental surfaces.
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