Improper Storage of Respiratory Masks for Resident on BiPAP and Nebulizer
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice and its own policy for a resident requiring BiPAP and nebulizer treatments. The resident was an adult male with a diagnosis of acute respiratory failure, admitted in February and assessed as cognitively intact on a recent Quarterly MDS, with an active diagnosis of acute respiratory failure. Physician orders in early March included BiPAP settings of 20/8 with 2L O2 at bedtime and Ipratropium-Albuterol inhalation solution every six hours. On the morning of 03/05/26, a surveyor observed the resident’s BiPAP mask and nebulizer mask lying unbagged on top of the nightstand when not in use. When shown the equipment, an LVN stated the masks should be bagged when not in use to avoid infection. The Unit Manager, ADON, and DON each acknowledged in separate interviews that the masks should have been bagged when not in use to avoid infections and that staff, including charge nurses and department heads, were responsible for ensuring respiratory delivery devices were bagged and dated. The facility’s written Oxygen Administration policy, revised 01/2025, specified that oxygen delivery devices are to be kept covered in an antimicrobial bag when not in use, which was not followed in this instance.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.