Improper Storage of Respiratory Equipment for Two Residents
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required respiratory support, as evidenced by improper storage of respiratory equipment. For one resident with diagnoses including heart failure, asthma, COPD, and respiratory failure, the nasal cannula and tubing were observed stored in a blue emesis bag attached to the concentrator, rather than in a clean, dated plastic bag as required to prevent environmental exposure and contamination. The resident reported using oxygen at night and was unsure when the tubing was last changed, indicating a lack of consistent adherence to proper storage and maintenance protocols. Another resident, admitted for short-term care with acute respiratory failure, shortness of breath, and obstructive sleep disorder, was observed with a CPAP mask left unbagged on the nightstand in his room. The resident stated he cleaned his own CPAP mask and tubing, but the tubing had not been bagged since his admission to the facility. Both residents were cognitively intact and had care plans and physician orders specifying the use of oxygen therapy or CPAP/BiPAP, with instructions for staff to monitor and store equipment appropriately. Interviews with facility staff, including the ADON, DON, and Administrator, confirmed that the expectation was for all respiratory equipment such as nasal cannulas and CPAP/BiPAP masks to be stored in clean, dated plastic bags when not in use. Staff acknowledged responsibility for ensuring proper storage and monitoring of respiratory equipment, but failed to notice or correct the improper storage for these residents. The facility's oxygen administration policy also required changing or cleaning equipment when contaminated, but this was not followed in these instances.