Failure to Properly Store Nebulizer Mask for Resident Requiring Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident who required the use of a nebulizer. Specifically, a resident with quadriplegia and a physician's order for Ipratropium-Albuterol via nebulizer every four hours as needed was observed to have her nebulizer mask left unbagged on a nightstand when not in use. The resident's comprehensive care plan did not include a plan for nebulizer use, and her MDS assessment did not reference the need for a breathing device. Multiple staff members, including an RN, ADON, and DON, confirmed that the mask should have been bagged when not in use to prevent infection and that this was an expected practice during nursing rounds. The facility's policy on respiratory nurse training outlines the need for skilled nursing services and proper respiratory care interventions, but this was not followed in the case of the resident observed. The failure to properly store the nebulizer mask was identified through observation, interviews, and record review, and staff acknowledged that not bagging the mask could lead to bacterial buildup and infection risk.