F0880

D

Infection Control Failures in CPAP Handling, Hand Hygiene, and Catheter Management

Saginaw, Michigan Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The deficiency involves failures in the facility’s infection prevention and control practices related to respiratory equipment, hand hygiene during medication administration and meal service, and urinary catheter management. For one resident using CPAP therapy, the facility’s own policies required staff to clean CPAP masks weekly and store them in a plastic bag when not in use. Surveyors twice observed this resident’s dry CPAP mask sitting on the nightstand next to a dirty urinal, with an empty, dated plastic storage bag hanging on the wall above the bed. The resident reported that he had used the CPAP mask during the night and removed it early in the morning, and that no staff placed it in the bag or cleaned it; instead, a family member cleaned the mask. In a phone interview, the family member confirmed she was the only one who cleaned the mask and knew it should be stored in the plastic bag, while the infection control nurse stated all CPAP masks were to be cleaned and stored in a sealed plastic bag when not in use.

Additional deficiencies were identified during medication pass observations. One RN retrieved medications from an in-room cabinet, prepared them on the medication cart, and administered them without any mention of hand hygiene before or between these steps. Another RN left an unlocked medication cart and treatment cart unattended in the team room when walking away at shift change, and a review of the controlled medication shift change log showed a missing off‑going nurse signature on a prior date, despite the form stating discrepancies should be reported to nursing administration; instead, staff reported using a sticky note to remind the nurse to sign later. On another unit, an LPN began a medication pass without performing hand hygiene, unlocked an in‑room medication cabinet, prepared medications on the cart, administered them, and then donned gloves for eye drops, removed the gloves, and continued handling the medication cabinet and cart without documented hand hygiene between tasks. A different LPN prepared and administered oral medications and nasal sprays without hand hygiene prior to preparation, washed hands only after oral medication administration, then donned gloves for nasal spray application, used the resident’s remote control, changed gloves, but did not wash hands between glove changes, while commenting on staffing shortages and frequent call lights.

Dining service and urinary catheter care also reflected infection control lapses. During meal tray delivery, kitchen staff plated food with gloves and loaded trays into insulated carts, but when trays were passed to residents in their rooms, no hand hygiene was offered to the residents before meals. For another resident with a 16 French Foley catheter, admission documentation noted milky discharge at the catheter insertion site of the penis, and observations included that the catheter bag was not kept off the floor, contrary to infection control standards. Collectively, these observations and interviews showed the facility did not consistently follow its own policies and procedures for hand hygiene during medication administration and meals, proper storage and cleaning of CPAP equipment, and appropriate handling of urinary catheter equipment, as cited by surveyors as increasing the risk for cross contamination, respiratory infection, and contamination during meals and medication administration with risk of resident illnesses and hospitalization.