Failure to Store Respiratory Equipment and Perform Dressing Changes per Infection Control Policy
Penalty
Summary
The facility failed to ensure the safe handling, labeling, and storage of respiratory therapy equipment, specifically nebulizer and BiPAP masks, for multiple residents. Observations revealed that a resident with COPD, HIV, dementia, and other conditions had a nebulizer mask left unbagged and unlabeled on the nightstand on multiple occasions. Staff interviews confirmed a lack of awareness or adherence to the facility's infection control policy, which requires respiratory equipment to be stored in a protective bag marked with the date and resident's name. The Director of Nursing confirmed that the expected practice was not followed. Another resident with a history of pneumonia, chronic pulmonary edema, and tracheostomy status was observed to have a BiPAP mask left unbagged and exposed to the environment on several occasions. The resident reported that staff often allowed the mask to fall on the floor and did not store it in a protective bag. Staff interviews further confirmed that the BiPAP mask was not stored according to infection control procedures, and the DON reiterated the requirement for proper storage. Additionally, the facility failed to perform dressing changes as ordered for a resident with a PEG tube. The resident's dressing was observed to be soiled and dated several days prior, despite a physician's order for dressing changes every shift. Staff confirmed the dressing had not been changed as required, and the DON stated that daily dressing changes were expected. These findings demonstrate lapses in infection prevention and control practices related to respiratory equipment and gastrostomy site care.