Improper Storage of Nebulizer Equipment After Respiratory Treatment
Penalty
Summary
Surveyors identified a deficiency in the facility’s provision of respiratory care and infection control for a resident requiring nebulizer treatments. The resident was an older female with COPD and hypertension, with moderately impaired cognition (BIMS score of 10). Her baseline care plan and MDS documented active treatment for COPD, including monitoring for respiratory distress, monitoring oxygen saturation as ordered, and administering medications per order. Physician’s orders directed Ipratropium-Albuterol nebulizer treatments every eight hours for two days, with a start date of 01/01/2026 and an end date of 01/02/2026. The MAR showed the last breathing treatment was administered on 01/02/2026. On 01/06/2026, during an observation, the resident was found lying in bed with the nebulizer machine on the nightstand approximately three feet from the head of the bed. The nebulizer mask and tubing were still connected to the machine and hanging from the side of the nightstand, not stored in a bag. The resident did not recall when she last received a breathing treatment. An LVN, who stated he had not provided the treatment, acknowledged that the nebulizer mask should have been bagged when not in use to prevent respiratory infection and that it appeared someone had given a treatment and failed to bag the mask. The Administrator and DON both stated that all respiratory items, including nebulizer masks, should be stored in a bag when not in use for infection control, and the DON added that the mask should be dated and that the nurse providing the treatment was responsible for proper storage. The facility did not have a written policy specifically addressing storage of breathing masks and tubing.
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