Failure to Unplug Nebulizer After Use
Penalty
Summary
The facility failed to maintain patient care-related electrical equipment in accordance with the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 Edition section 10.3. During a recertification survey, it was observed that Nebulizer ASP 59, located in a specific room, was plugged in and not in use. The manufacturer's user manual for the nebulizer specified that to reduce the risk of electrocution, the nebulizer should be unplugged after use. This requirement was not followed, as evidenced by the observation of the plugged-in nebulizer. During interviews, a registered nurse acknowledged that the nebulizer should have been unplugged, and the Director of Nursing confirmed awareness of the issue. The deficiency was identified as a failure to adhere to the prescribed maintenance procedures outlined in the nebulizer's user manual, which is a requirement under the relevant NFPA standards and federal regulations.
Plan Of Correction
Plan of Correction: Approved May 5, 2025 ELEMENT 1 Nebulizer was unplugged at time of identification by surveyor during the facility New York State Department of Health annual recertification survey. Nursing staff assigned to that house was re-educated to need to unplug the nebulizer after use at the time the nebulizer was identified as being plugged in. ELEMENT 2 All nebulizers have been checked to ensure that they have been unplugged and comply with manufacturer requirements. No issues identified. ELEMENT 3 Education will be provided to staff regarding PCREE including but not limited to the following: - Testing and inspection prior to use - Availability of owner's manual for all Patient Care Electrical Equipment to determine appropriate use and safety measures specific to the equipment - Risks associated with the use of Patient Care Electrical Equipment During weekly environmental rounds, checking of Patient Care Electrical Equipment will be added to items reviewed to ensure compliance with safe use of this equipment. ELEMENT 4 Audits on 25% of Patient Care Electrical Equipment will be completed monthly to ensure that the Patient Care Equipment is being used per owner's manual. Results will be recorded on the Equipment audit tool. These audits with results and trends will be reported to the monthly Quality Assurance Committee. Any equipment noted to be out of compliance will be corrected at time of audit with education in real time to clinical staff. Audits will continue until the facility achieves 100% compliance. Quality Assurance Committee will make recommendations as to ongoing need for frequency and duration of audits. Maintenance Director responsible for ongoing compliance.