Improper Storage of Nebulizer Mask for Resident Receiving Respiratory Treatments
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care consistent with professional standards, the resident’s comprehensive person-centered care plan, and the resident’s goals and preferences for one resident who required respiratory care. The resident was an older female with COPD and acute and chronic respiratory failure with hypoxia, admitted in February 2026. Her comprehensive care plan, dated 02/09/2026, documented COPD, and an intervention added on 02/17/2026 directed staff to provide nebulizer treatments as ordered. A physician’s order dated 02/16/2026 prescribed Ipratropium-Albuterol via nebulizer four times daily for seven days for acute and chronic respiratory failure with hypoxia. On 02/17/2026 at 10:08 AM, surveyors observed the resident lying in bed asleep with a nebulizer on her nightstand and the attached breathing mask not stored in a bag. Multiple staff interviews confirmed that the nebulizer mask should have been stored in a bag when not in use as part of infection control practices. A CNA stated that if the nurse forgot, she could obtain a bag and that she would discard a mask found on the floor and notify the nurse. An RN, the ADON, the Administrator, and the DON each stated that nebulizer masks and other respiratory items were expected to be bagged when not in use, and that nurses were responsible for ensuring this occurred after treatments. The facility did not have a written policy specifically addressing storage of respiratory items when not in use.
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