Failure to Properly Store Respiratory Equipment
Penalty
Summary
The facility failed to ensure that respiratory equipment, specifically nebulizer masks and CPAP masks, were stored in accordance with facility policy and standard precautions. Observations revealed that for two residents with significant respiratory conditions, their respiratory masks were repeatedly left unbagged on bedside tables, oxygen concentrators, or overbed tables, with the portions of the masks that made contact with the residents' faces exposed to environmental surfaces. The facility's policy required that oxygen masks be placed in labeled bags when not in use, but did not specifically address nebulizer masks. Despite this, staff interviews confirmed that the expectation was for all types of respiratory masks to be stored in bags to prevent contamination. For one resident with a history of pneumonia, COPD, and hypoxemia, the nebulizer mask was observed multiple times over several days to be unbagged and in direct contact with various surfaces in the resident's room. The resident reported using the mask twice daily and expressed concern about the mask being left out and not cleaned. Staff interviews revealed inconsistent practices regarding the replacement and storage of the mask, with some staff unsure if clean masks were provided or if used masks were properly bagged. The Director of Nursing and other staff acknowledged that masks should be stored in bags and that the responsibility for this task fell primarily to the nursing staff, with CNAs able to assist if they noticed improper storage. A second resident with acute hypoxic respiratory failure, pneumonitis, and obstructive sleep apnea also had both a CPAP mask and a nebulizer mask left unbagged on the overbed table. Multiple observations confirmed that the masks were not stored in bags as required. Staff interviews indicated that nurses were responsible for placing and removing the masks and that the expectation was for masks to be stored in labeled bags when not in use. However, staff were observed not following this protocol, and the Director of Nursing confirmed that all respiratory masks should be bagged to prevent contamination.