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Based on observation, interview, and review of policies and medical records, it was determined the facility failed to ensure implementation and monitoring of systems for mitigating potential infection control risks. This directly impacted 1 of 1 patient (#2) for whom a respiratory treatment was observed, and had the potential to impact all patients who received aerosolized respiratory medication administration at the facility. The failure to ensure implementation and monitoring of systems had the potential to expose patients to infections. Findings include:

Patient #2 was a 79 year old female admitted to the facility on 8/01/12 with a diagnosis of respiratory failure. Patient #2 was intubated, on a ventilator, and required suctioning every three to four hours for removal of excess secretions. In addition, Patient #2 received medications via a small volume nebulizer(SVN) which was connected to the ventilator circuit every four hours.

During an observation of cares provided by a Respiratory Therapist (RT) on 8/06/12 beginning at 3:00 PM, Patient #2 received a SVN. Upon completion of the treatment, the RT disconnected the nebulizer unit from the ventilator circuit. She shook out the residual moisture and placed the nebulizer cap and bottle into a plastic bag that was hanging on the side of the ventilator. The RT was not observed to clean or dry the SVN equipment before placing it into the bag.

A hospital policy, titled "PHYSICIAN ORDERS/MEDICATION DELIVERY, APPLIES TO RESPIRATORY THERAPY" dated 3/22/10, contained cleaning instructions for the SVN equipment as follows: "Unscrew the nebulizer cap and bottle. Wash all components in warm soapy water and rinse well. Air dry or hand dry with a clean, lint free cloth." The policy did not include instructions related to the frequency of cleaning the equipment.

During an interview on 8/07/12 beginning at 11:00 AM, the RT confirmed she had placed the SVN equipment directly into the plastic bag without cleaning it. She stated she did not rinse or clean the equipment after use. The RT reviewed the policy, and confirmed the policy did not include a frequency for cleaning the equipment.

During an interview on 8/07/12 beginning at 11:00 AM, the Director of Respiratory Therapy stated the policy was based on AARC Clinical Practice Guidelines, dated 1996. He printed a copy, titled "Selection of Device, Administration of Bronchodilator, and Evaluation of Response to Therapy in Mechanically Ventilated Patients." The guidelines included directions as follows: "Nebulizers should be changed or sterilized at conclusion of dose administration." Additionally, the guidelines stated "...change the nebulizer every 24 hours." The Director of Respiratory Therapy stated his department staff did not clean the nebulizer after use, and routinely changed the nebulizers on a weekly basis, rather than every 24 hours.

The facility did not develop a system for cleaning the SVN equipment between use.