Failure to Maintain Infection Control for Oxygen Equipment and Glucometer Use
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection prevention and control policies for oxygen and respiratory equipment storage/handling and for disinfection of shared blood glucose meters. Facility policy required oxygen and respiratory supplies to be changed weekly and when visibly soiled, and to be stored in labeled bags when not in use. Observations showed multiple residents’ respiratory devices and oxygen supplies left uncovered and improperly stored: a CPAP lying uncovered on a dresser, a nebulizer mask hanging uncovered on a walker, oxygen nasal cannula tubing lying on the floor, a BIPAP mask on a dresser and oxygen tubing draped over a wheelchair uncovered, and a VPAP mask lying over the machine uncovered. In one instance, an RN acknowledged that oxygen tubing should not be on the floor and nebulizers should not be stored on walkers, but then placed tubing that had been on the floor directly into an oxygen bag without cleaning and placed a nebulizer mask on a dresser. The Infection Preventionist later stated that oxygen tubing should be bagged when not in use, nebulizer masks should be cleaned and dried after each use, and CPAP/BIPAP/VPAP equipment should be cleaned and set up for nighttime use. The facility also failed to follow manufacturer instructions for disinfecting a shared glucometer. The TRUE METRIX Pro Glucose Meter manual required use of PDI Super Sani Cloth (or equivalent EPA-registered product) with all external surfaces kept wet for 2 minutes to disinfect the device. An LPN checked a resident’s blood sugar, wiped the glucometer with a Sani wipe, and then immediately returned it to its case, later stating that although she knew the dry time was 2 minutes, she did not realize the meter had to remain wet for that duration. Additionally, a resident with COPD, depression, and cardiomegaly had a physician order for continuous oxygen at 3 LPM via nasal cannula. This resident was observed not wearing oxygen, and a CNA picked the nasal cannula up from the floor and assisted the resident in placing it without replacing the tubing. The CNA stated the cannula and tubing should have been discarded and replaced when found on the floor, and the CNO confirmed oxygen supplies should be discarded and replaced weekly or when found on the floor and not used.
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