Failure to Change and Store Nebulizer Equipment per Facility Policy
Penalty
Summary
The facility failed to adhere to its own policy regarding the maintenance and storage of nebulizer equipment for two residents requiring respiratory care. For one resident with physician orders for Ipratropium-Albuterol nebulizer treatments as needed for wheezing, observations revealed that the nebulizer mask was stored in a plastic bag dated over a month prior, with no documented evidence that the tubing and mouthpiece had been changed weekly as required by facility policy. Interviews with nursing staff and review of the electronic Medication Administration Record (eMAR) confirmed that there was no documentation of the equipment being changed since the date on the bag. Another resident, also with physician orders for Ipratropium-Albuterol nebulizer treatments, was observed multiple times with the nebulizer mask left uncontained, either on the resident's lap or on the bedside table, rather than being stored in a plastic bag as required. Nursing staff confirmed during interviews that the nebulizer mask should have been stored in a plastic bag when not in use, in accordance with facility policy. These deficiencies were identified through direct observation, interviews with staff, and review of medical records, which consistently showed a lack of compliance with the facility's established procedures for cleaning, changing, and storing nebulizer equipment. The failure to follow these procedures was confirmed by both the LPN Supervisor and the Infection Preventionist, who acknowledged the absence of documentation and proper storage practices for the residents' respiratory care equipment.