| 7 |
BENEFIS SENIOR SERVICES |
275012 |
2621 15TH AVE S |
GREAT FALLS |
MT |
59405 |
2017-03-09 |
441 |
D |
0 |
1 |
KTFZ11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure nebulizers were cleansed after each treatment and cleaned daily with soapy water for 1 (#14) of 24 sampled residents. This practice had the potential to promote the growth of bacteria and spread of infection to a resident receiving nebulizer treatments, and specifically for those receiving multiple treatments in a day. Findings include: Resident #14 was admitted to the facility on [DATE] with heart attack, [DIAGNOSES REDACTED], anxiety, depression, sacral pressure sore, chronic obstructive pulmonary disease, renal insufficiency, diabetes, and hypertension. a) Unbagged and uncovered nebulizer mask During an interview on 3/6/17 at 4:00 p.m., resident #14's nebulizer mask was placed on the bed side table. During an interview on 3/7/17 at 2:00 p.m., resident #14's nebulizer mask was placed on the bed side table next to the bed. During an interview on 3/7/17 at 3:02 p.m., resident #14's nebulizer mask was placed on the bed side table next to the bed. During this time, the resident was interviewed about bagging the nebulizer mask after treatments to prevent contamination. She stated no one told her to bag the mask, and no one bagged it for her. b) Rinsing of the nebulizer mask, pipe, and cup, after each treatment During an interview on 3/6/17 at 4:00 p.m., resident #14 stated she was independent with the administration of the nebulizer treatment as she also administered it at home. She stated the nurse set it up the treatments for her and left, and the resident turned it off at the end of the treatments. She stated no, they don't when asked if nursing came back within the 10 - 15 minutes of the treatment as it finalized and rinsed the device after each use. During an interview on 3/7/17 at 2:15 p.m., staff member C stated the residents use either the pipe or the mask, depending on their abilities. After the treatment, the resident turned off the machine and laid the mask or the pipe on the bed or the table. Staff member C stated she was not aware of any process for the cleaning of the mask, pipe, or the cup, but the tubing was changed regularly and labeled with the date when changed. During an interview on 3/8/17 at 8:55 a.m., staff member N stated she did not rinse the nebulizer attachments, but mainly assessed the resident's status, lungs, and the effectiveness of the treatment. Review of the Benefis Health System Treatment/Guideline, titled Respiratory Therapy Benefis Senior Services, showed Nebulizers are rinsed after each use and air dried in the room. They are washed with soapy water, rinsed and air dried on the evening shift after the last treatment of [REDACTED]. |
2020-09-01 |