Failure to Store Respiratory Equipment in a Sanitary Manner
Penalty
Summary
The facility failed to ensure that a resident's respiratory care equipment, including a BiPAP mask, nebulizer mask, and oxygen nasal cannula, was stored in a sanitary manner when not in use. Observations over several days revealed that the BiPAP mask was placed directly on the bedside table, the nebulizer mask was left on top of the BiPAP machine or bedside table, and the oxygen cannula was found lying on the floor beside the bed. These items were not stored according to facility protocol, which requires respiratory equipment to be placed in a dated plastic bag when not in use. The resident involved had multiple complex medical conditions, including hypertension, obstructive sleep apnea, pulmonary edema, vascular dementia, neurogenic bladder, hemiparesis following a stroke, contracture of the right hand, and muscle weakness. The resident was dependent on staff for all activities of daily living except eating and required the use of supplemental oxygen and a non-invasive ventilator. The care plan documented the need for BiPAP use as ordered and monitoring for respiratory insufficiency, but lacked specific staff instructions for the care and storage of the BiPAP mask, nebulizer mask, and oxygen nasal tubing. Interviews with facility staff, including a licensed nurse, a CNA, and an administrative nurse, confirmed that all respiratory equipment not in use should be stored in a dated plastic bag per facility protocol. Staff acknowledged responsibility for ensuring proper storage but failed to do so in this case. The facility's infection surveillance policy emphasized the importance of monitoring adherence to infection prevention and control practices, but these were not followed for the resident's respiratory equipment.