Deficient Infection Control in Respiratory Equipment Care
Penalty
Summary
Surveyors identified deficiencies in the facility's infection prevention and control program related to the care and maintenance of respiratory equipment for two residents. For one resident with orders for both oxygen therapy and a positive airway pressure (PAP) device, observations revealed that the PAP device was missing its required filter, the tubing was discolored, bent, and coated with visible residue, and the mask had not been cleaned. The resident's nasal cannula was repeatedly observed resting on the floor, and the oxygen concentrator's filters were covered in dense, gray, fuzzy sediment. Facility policies required regular cleaning and replacement of these items, but these procedures were not followed. Another resident, who had diagnoses including sleep apnea, emphysema, and COPD, was also found to have a PAP device mask with visible brown and black flecks on the inside surface during multiple observations. The mask was left on various unclean surfaces, such as a used clothing protector, a blanket, and a hat, rather than being properly cleaned and stored. The resident's nasal cannula was also observed lying on the floor. Staff interviews confirmed that the equipment should have been cleaned daily and stored appropriately, but these practices were not consistently implemented. Record reviews showed that both residents had physician orders and care plans specifying the need for daily cleaning of respiratory equipment and proper storage of tubing and masks. Despite these documented requirements, staff failed to ensure that the equipment was maintained in a clean and sanitary condition, and failed to keep tubing and cannulas off the floor, as confirmed by both nursing staff and the Director of Nursing during interviews.