Failure to Follow Infection Control Practices for Respiratory Equipment
Penalty
Summary
The facility failed to follow infection control practices for two residents who required respiratory equipment. For one resident with a history of pneumonia, the oxygen cannula in use was not dated, and a nebulizer mask was found undated and left exposed on the nightstand, rather than being stored in a plastic bag as required. The resident's physician order specified that the nasal cannula and mask should be changed weekly, and facility policy required respiratory equipment to be labeled, dated, and stored in a plastic bag when not in use. Staff interviews confirmed that these procedures were not followed, and the equipment was not properly stored or dated. For another resident, also with a diagnosis of pneumonia, the nebulizer mask had not been changed since admission, despite physician orders and facility policy requiring weekly changes. The mask was observed in a belongings bag with an outdated label, and the resident confirmed that the mask had not been replaced since admission. Staff interviews revealed that the responsibility for changing the equipment was assigned to the night shift, but the change had not occurred as scheduled. The equipment was also not stored according to infection control protocols. Both residents' records and staff interviews indicated a lack of adherence to established infection control policies regarding the maintenance, labeling, and storage of respiratory equipment. The facility's own procedures required weekly changes and proper storage of such equipment to prevent contamination, but these steps were not consistently implemented for the residents reviewed.