Failure to Maintain Safe and Clean Nebulizer Equipment for Resident Receiving Respiratory Care
Penalty
Summary
A deficiency occurred when a resident requiring respiratory care was not provided with safe and appropriate management of their nebulizer equipment. The resident, who had diagnoses including Alzheimer's disease, unspecified dementia, and muscular atrophy, was severely cognitively impaired and required assistance with mobility and activities of daily living. Physician orders indicated the resident was to receive DuoNeb treatments every six hours for five days, which was administered as scheduled. However, the resident's care plan did not include any problems or interventions related to nebulizer treatments. During observations, the resident's nebulizer mask was found uncovered, with the elastic band stretched around the nebulizer machine, and a dried white substance present on the mask. The mask and tubing were not dated or covered, and there was no documentation of when they were last changed. Interviews with nursing staff revealed that while masks and tubing were reportedly changed weekly and should be dated and covered, there was no specific documentation to confirm this practice. The Director of Nursing was unaware that the resident was still receiving nebulizer treatments and did not provide a facility policy for respiratory care when requested.