A resident with intact cognition and respiratory treatment orders received albuterol nebulizer treatments, but staff left the nebulizer tubing and mask on the resident’s refrigerator without dating, initialing, or storing them in a bag after use. The LPN confirmed she administered the treatments and did not follow the facility’s policy for labeling and storage of the nebulizer equipment.
Improper Storage of Nebulizer Equipment: A resident with asthma, prior respiratory failure, and oxygen use had a nebulizer ordered multiple times daily, but the mask was observed face down on the bedside dresser without a labeled storage bag when not in use. An RN confirmed the mask should be stored in a plastic bag, and the DON stated nebulizer masks should be cleaned and returned to a labeled bag rather than left on the dresser.
Improper Cleaning of Non-Invasive Ventilation Equipment: A resident with COPD, chronic respiratory failure, and shortness of breath used an AVAPS-AE ventilator with a full face mask. The order required the mask to be cleaned every morning and air dried, and the facility policy required daily cleaning of the mask and tubing with warm water and soap. Staff instead reported cleaning the mask with personal cleansing wipes, alcohol wipes, or water-soaked paper towels, and they had not cleaned or changed the tubing.
Nebulizer tubing and face mask were found connected to a nebulizer machine beside a resident’s bed, not dated, and not stored in a plastic bag when not in use. The resident had active nebulizer orders for ipratropium-albuterol and PRN albuterol, and the DON confirmed the tubing should be dated and properly stored per policy.
Oxygen Not Administered as Ordered: A resident with chronic respiratory failure and severe cognitive impairment was ordered continuous O2 at 2 L/min via nasal cannula, but surveyors observed the resident receiving 1 L/min on multiple occasions. An LPN stated the resident should not have been on 1 L of oxygen, and a Unit Manager confirmed the resident was receiving less than the ordered amount.
A resident with anemia, Parkinson’s disease, respiratory symptoms, and a history of pneumonia had physician orders for routine Ipratropium-Albuterol nebulizer treatments. Surveyors observed the resident’s nebulizer machine on the bedside table with the mask lying on top, uncovered and undated, despite a facility policy requiring oxygen-related tubing, cannulas, and masks to be stored in a plastic bag when not in use and changed weekly and as needed. An LPN confirmed the resident received regular breathing treatments, had been treated earlier that day, and acknowledged that the nebulizer mask and tubing should have been covered and dated but were not.
Oxygen Tubing Not Labeled With Date and Time: A resident with COPD, pleural effusion, and atrial fibrillation had O2 via nasal cannula as needed, but observations showed the oxygen tubing was not labeled with the date and time. An LPN confirmed the tubing was not labeled and should have been, and the DON stated staff were expected to label oxygen tubing with the date and time it was changed.
A resident's nasal cannula used for oxygen therapy was repeatedly found lying on the floor without being stored in a bag, contrary to facility policy. An LPN confirmed the equipment was not properly labeled or stored between uses, despite the resident's recent use of oxygen.
A resident's nebulizer tubing was not changed and dated weekly as required by physician orders and facility policy. Observations showed the tubing was dated over a month prior, and staff interviews confirmed it should have been changed weekly but was not.
Two residents did not receive respiratory care in accordance with professional standards. One resident's suction equipment was not labeled or dated as required, and another resident received oxygen at a higher flow rate than ordered by the physician. These deficiencies were confirmed through observations and staff interviews.
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