Failure to Maintain Sanitary Conditions for Respiratory Equipment
Penalty
Summary
The facility failed to maintain sanitary conditions of respiratory equipment for Resident R118, who was diagnosed with congestive heart failure, atrial fibrillation, and chronic obstructive pulmonary disease. According to the facility's policy on Respiratory Equipment Maintenance, BIPAP/CPAP equipment should be changed as needed for soiling or equipment integrity, and the equipment should be stored in a labeled bag. However, during an observation, Resident R118's fitted face mask was found in a basket on a cart without a label or bag. A Registered Nurse confirmed that the facility did not adhere to the policy, resulting in unsanitary conditions for the respiratory equipment of one of the four residents reviewed.
Plan Of Correction
R118 has been discharged. On the day of the findings, all residents with BIPAP/CPAP therapy were reviewed to ensure all BIPAP/CPAP masks not in use were in an equipment treatment bag with the residents last name, room number and date. All RNs and LPNs will be educated by the Director of Nursing and/or designee that when a BIPAP/CPAP machine is not in use that the mask should be placed in an equipment treatment bag with the residents last name, room number and date. The Director of Nursing and/or designee will audit BIPAP/CPAP equipment when not in use to ensure the BIPAP/CPAP mask is placed in an equipment treatment bag with the residents last name, room number and date. Audits will be completed weekly for 4 weeks, then monthly for 2 months, or until substantial compliance is achieved. Results will be reviewed at the Quarterly QAA meeting.