Failure to Follow Enhanced Barrier Precautions and Sanitary Nebulizer Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP) and the sanitary handling and storage of respiratory treatment devices. Surveyors observed one resident’s oxygen tubing wound around a portable oxygen tank, and the nebulizer mouthpiece attached to a medication bowl that still contained a small amount of fluid and remained attached to the nebulizer machine. Another resident’s nebulizer machine was observed with the face mask and medication bowl still attached and containing fluid, lying on a chair beside the bed with the tubing wound up with a blanket and a back brace placed on top of the nebulizer. A licensed nurse reported that after completing breathing treatments, she rinsed the medication cup and mask, dried the mask with a paper towel, allowed the equipment to air dry, and then placed it in a plastic bag, and an administrative nurse confirmed that staff were expected to clean the mouthpiece and medication cup, allow them to dry, and place them in a bag for infection control. The deficiency also includes failure to follow EBP during catheter care for a resident with an indwelling catheter. During an observed toileting and catheter care episode, two CNAs entered the resident’s room, donned gloves, and assisted the resident with toileting and clothing changes after a bowel movement. The catheter bag was emptied into a plastic urinal and placed on the back of the toilet, then the urine was poured into the toilet. Afterward, both CNAs removed their gloves; only one washed her hands before leaving the room, and the other exited the room and escorted the resident to the dining room without hand hygiene. In interviews, both CNAs acknowledged they forgot to don the EBP gowns posted on the resident’s door, and one CNA stated that handwashing was supposed to be done before and after handling a patient or a catheter. The facility’s infection control surveillance policy documented that all staff are to be educated on infection control prevention practices as they relate to their job.
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