Infection Control Failures in Respiratory Equipment Storage, PPE Use, and Laundry Handling
Penalty
Summary
Surveyors identified multiple infection prevention and control deficiencies involving respiratory equipment, personal protective equipment (PPE) use, and laundry handling. During an initial walk-through, one resident’s CPAP mask was found lying directly on the bedside table without being stored in a sanitary container. Three other residents’ nebulizer masks were also observed either on bedside tables or hanging over a side table and lying in a magazine rack, all without sanitary containers. Facility nursing leadership later stated that respiratory equipment should be rinsed, laid to dry covered, and then placed in a marked bag labeled with the resident’s name and date when not in use, which was not done in these cases. Surveyors also observed improper handling of dirty laundry and failure to follow Enhanced Barrier Precautions (EBP) PPE requirements. A CNA was seen carrying unbagged dirty laundry close to their uniform down a hallway to a dirty laundry barrel, contrary to the administrative nurse’s expectation that staff move the laundry tub to the resident’s door and avoid carrying dirty laundry next to their clothing. Another CNA was observed holding a graduated cylinder containing dark amber urine while wearing only gloves and no additional PPE, despite the resident having a urinary catheter and signage on the door indicating required PPE for EBP. Staff interviews confirmed that all CNAs had been trained on EBP and that a gown and gloves were expected for personal care of residents with urinary catheters. The facility was unable to provide a policy for EBP when requested, despite having written policies for respiratory care and laundry protocols.
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