Failure to Properly Contain Nebulizer Mask per Facility Policy
Penalty
Summary
The facility failed to contain a resident’s nebulizer mask according to its own policy for administering medications through a small-volume handheld nebulizer. A resident with diagnoses including anemia and type 2 diabetes mellitus with hyperglycemia was observed sitting in a wheelchair in her room with her nebulizer mask not in use and not contained. The resident reported she had flu and COVID-19 about a week prior and that staff provide her nebulizer machine and mask daily when she feels short of breath. The Quality Director/Infection Preventionist confirmed that the nebulizer mask should be stored in a plastic bag when not in use to avoid contamination and stated that the resident had recently been positive for COVID-19 and was last on contact/droplet precautions about one week earlier. The resident’s active physician order dated 2/1/26 showed an order for DuoNeb inhaler solution every shift for congestion via inhalation, and the facility’s policy dated 2/2025 specified that when nebulizer equipment is completely dry, it should be stored in a plastic bag labeled with the resident’s name and date, which was not done in this case. This deficiency involved one resident reviewed for oxygen equipment out of a total sample of 11 residents and was identified through observation, interview, and record review, demonstrating noncompliance with the facility’s infection control and nebulizer equipment storage procedures.
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