Improper Storage of Respiratory Equipment for Residents Requiring Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required such care, as evidenced by improper storage of respiratory equipment. For one resident with chronic obstructive pulmonary disease, the nasal cannula attached to a portable oxygen tank was observed hanging on the back of her wheelchair, unbagged, with the prongs touching the wheelchair brake. The resident confirmed that she used this nasal cannula whenever she left her room. A licensed vocational nurse (LVN) acknowledged that the nasal cannula should have been bagged when not in use to prevent infection and disposed of the improperly stored cannula upon discovery. For another resident diagnosed with respiratory failure and obstructive sleep apnea, both the breathing mask for nebulizer treatments and the CPAP mask were found unbagged—one on top of a side table and the other inside a drawer. The resident was unaware of where staff stored these items after use. Upon observation, an LVN confirmed that both masks should have been bagged when not in use and took steps to replace and clean the equipment. Interviews with the Director of Nursing (DON) and the Administrator confirmed that the expectation was for all respiratory equipment, including nasal cannulas, breathing masks, and CPAP masks, to be bagged when not in use to prevent cross-contamination and infection. However, the facility did not have a specific policy in place for bagging these items, and staff failed to consistently follow infection control practices as required by professional standards and the residents' care plans.