Failure to Contain Nebulizer Masks per Infection Control Policy
Penalty
Summary
The facility failed to properly contain nebulizer masks for four residents who required respiratory care, as observed during a survey. The facility's policy requires that nebulizer masks be placed in a labeled bag when not in use to prevent contamination. However, surveyors observed that the nebulizer masks for several residents were left uncovered on nightstands or other surfaces, rather than being stored in bags as required by policy. Residents affected by this deficiency had significant medical histories, including chronic pulmonary embolism, asthma, chronic obstructive pulmonary disease (COPD), heart failure, and pneumonia. For example, one resident with asthma and pulmonary embolism had their nebulizer mask left on the nightstand without a bag. Another resident with COPD, pleural effusion, and heart failure also had their nebulizer mask left uncovered. Staff interviews confirmed that the masks should have been contained in bags for infection control, and staff acknowledged awareness of the policy but did not consistently follow it. Additional observations included a resident with pneumonia and moderate cognitive impairment whose nebulizer mask was left on a bedside table, and another resident with COPD and a heart assist device whose mask was placed on top of their LVAD, not in a bag. Staff, including nurses and the Director of Nursing, confirmed that the masks should be stored in plastic bags to prevent contamination, but this was not done for the residents observed.