F0695

E

Failure to Clean, Store, Change, and Label Respiratory Equipment per Orders and Policy

Fort Worth, Texas Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide safe and appropriate respiratory care consistent with professional standards, physician orders, and care plans for multiple residents using BIPAP and oxygen therapy. For one male resident with obstructive sleep apnea who required BIPAP while sleeping or napping, the care plan and physician orders directed staff to assist with applying and removing the BIPAP mask at bedtime and in the morning, to clean the mask with warm soapy water and air dry as needed, and to clean the reservoir weekly. During observation, his BIPAP mask was found lying unbagged on his nightstand among other personal items, with a greasy substance visible on the mask. The resident reported that staff had removed the mask that morning, placed it on the nightstand, and had not cleaned or bagged it, contrary to the facility’s BIPAP/CPAP administration policy and the infection control expectations described by nursing leadership.

Another resident with COPD and multiple fractures required continuous oxygen at 4 L/min via nasal cannula, with a physician order to change the oxygen tubing, nebulizer circuit, and humidifier bottle weekly on the night shift, to label them when changed, and to change and label them every 24 hours as needed when visibly soiled. The resident’s care plan addressed oxygen use and monitoring for respiratory symptoms but did not address the frequency of oxygen tubing changes or labeling. Review of the treatment administration record showed that the oxygen tubing had not been changed on several consecutive days, and during observation the resident was wearing an undated nasal cannula and had an undated oxygen water bottle. The resident stated the tubing had not been changed since admission. Documentation later showed that an LPN changed the tubing and water that same day, but at the time of the initial observation the equipment was not dated as required by the physician order and facility practice.

A third resident with obstructive sleep apnea and asthma had a physician order for BIPAP use with specified settings but no orders addressing cleaning frequency or storage of the BIPAP equipment. Her care plan did not address BIPAP use, storage, or cleaning. During observation, her BIPAP mask was found in the top drawer of her nightstand with visible oil buildup, moisture, and a cloudy appearance, and it was not stored in a bag. The resident reported she did not know when the mask was last cleaned and that she used it during naps and at night. Interviews with nursing staff and the DON confirmed that standard practice and protocol required BIPAP masks to be cleaned as needed, bagged when not in use, and oxygen equipment to be changed and dated at least weekly and as needed. These observations and record reviews showed that the facility did not follow its own BIPAP/CPAP administration policy, infection control practices, and physician orders for cleaning, storing, changing, and labeling respiratory equipment for these residents.