Failure to Maintain Clean and Sanitary Storage of Respiratory Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required the use of non-invasive ventilators (BiPAP) and oxygen therapy. Observations revealed that the BiPAP masks for both residents were not stored in plastic bags when not in use, as required by facility policy and infection control standards. Instead, the masks were left exposed on nightstands or draped over equipment, with the plastic storage bags either underneath the mask or hanging on a wall hook nearby. Multiple staff members, including medication aides and licensed vocational nurses, confirmed during interviews that the masks should have been stored in plastic bags to prevent contamination, but were unable to explain why this was not done. One resident had a history of acute respiratory failure, COPD, pneumonia, heart failure, and obstructive sleep apnea, and was receiving nightly BiPAP therapy with oxygen as ordered by her physician. Her care plan did not address the need for BiPAP or oxygen therapy. The other resident, with diagnoses including hemiplegia following a stroke, diabetes, morbid obesity, and obstructive sleep apnea, also received nightly BiPAP and continuous oxygen therapy. Her care plan included interventions for oxygen therapy and BiPAP use, noting frequent refusals of the BiPAP, but did not address the improper storage of respiratory equipment. Interviews with the Director of Nursing and staff confirmed the expectation that BiPAP masks be stored in plastic bags when not in use for infection control purposes. The facility's policies and in-service training materials also specified that oxygen therapy equipment must be kept clean and sanitary, with masks and cannulas covered when not in use. Despite these policies and training, the required infection control practices were not consistently followed, as evidenced by the improper storage of respiratory equipment for both residents.