Failure to Ensure Safe Use of CPAP Machine
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident using a home CPAP machine. The resident, who was admitted with diagnoses including COPD, asthma, and obstructive sleep apnea, did not have a physician's order for the use of the CPAP machine in the facility. Additionally, there was no assessment of the CPAP machine's integrity, no monitoring of the resident's respiratory condition or response to therapy, and no care plan that included interventions for CPAP therapy. Observations and interviews revealed that the resident's CPAP machine and mask had not been checked or cleaned according to the manufacturer's guidelines, which included daily cleaning of the mask and tubing. The resident confirmed that the mask and tubing had not been changed for several weeks. The facility's staff, including a registered nurse and a respiratory therapist, acknowledged the lack of a physician's order, assessment, and care plan for the CPAP machine, as well as the failure to clean the equipment as required. The Director of Nursing and the Infection Preventionist also confirmed these deficiencies, emphasizing the importance of having a physician's order, a care plan, and proper cleaning procedures to prevent respiratory infections. The facility's policies and procedures, as well as the CPAP machine's user manual, outlined the necessary steps for safe and effective use of the CPAP machine, which were not followed in this case.
Plan Of Correction
A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Resident 29's physician assessed the use of the CPAP machine and provided orders for its use and monitoring. The licensed nurse transcribed the physician order for the use and monitoring of Resident 29's CPAP machine on 2/26/2025. The Director of Maintenance evaluated the CPAP machine's safety and integrity on 2/26/2025. The licensed staff are monitoring Resident 29's use of CPAP machine daily and documenting the monitoring in the treatment administration record. The CPAP machine is cleaned routinely per manufacturer's guidelines by the Licensed Vocational Nurses. The IDT developed and initiated a care plan for the use of Resident 29's CPAP including interventions for assessment and monitoring of Resident 29's respiratory status and care of the CPAP machine on 2/26/2025. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken; Residents using home CPAP machines are potentially affected by the facility practice. The Assistant Director of Nursing audited all residents who use CPAP machines. A total of 3 residents use CPAP machines. 0 of 3 residents CPAP machines were brought from home. No other residents identified affected by the facility practice. The IDT audited care plans of residents who use a CPAP machine for respiratory conditions to ensure interventions including an assessment, physician order, monitoring and cleaning were present on 2/26/2025. C. What measures will be put into place or what systematic changes the facility make to ensure that the deficient practice does not recur; The Director of Nursing/designee will re-educate the nursing staff on or before 3/21/2025, re: the facility policy and procedures, Care Planning, with emphasis on residents with CPAP therapy must have person-centered interventions based on the assessment including evaluation of the safety and integrity of a CPAP machine, when brought from home, No Smoking sign at the resident's door, tubing and mask materials, routine evaluation of respiratory condition through pulse oximeter and routine cleaning per manufacturers guidelines for the CPAP machine. The Interdisciplinary Team will evaluate newly admitted residents for to identify residents with CPAP therapy to ensure the completion of an assessment, physician order and comprehensive person-centered care plan with interventions for CPAP therapy, routine cleaning of the mask and replacement of the tubing, and cleaning of the CPAP machine. Charge nurses will complete routine pulse oximetry each shift of residents with CPAP machines. D. How the facility plans to monitor its performance to make sure solutions are sustained; The Infection Prevention Nurse/designee will monitor residents who use CPAP therapy to ensure cleanliness of the mask, tubing and machine per manufacturer's guidelines to reduce the risk of residents developing respiratory infection. The Charge Nurse will monitor the residents' respiratory health, assess the resident's pulse oximetry and document in the medication administration record each shift. Concerns identified will be corrected at the time of observation and reported to the Director of Nursing. The Director of Nursing will monitor the licensed nurses' performance through observation and IPN reports; and provide re-education or progressive disciplinary action as indicated. The DON/designee will report trends identified in CPAP therapy to the Quality Assurance committee during the quarterly QA&A meeting for the purpose of process improvement changes to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025 --- F697 Pain Management CFR(s): 483.25(k) A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; The licensed nurse completed a pain assessment of Resident 65 to ensure current pain management program is effective on 2/24/2025. CNA 1 received 1:1 re-education on the facility procedure to report resident complaints of pain to the charge nurse for further evaluation on 2/24/2025. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken; Residents cared for by certified nurse assistant 1 are potentially affected. The Charge Nurse interviewed residents cared for by CNA 1 on 2/24/2025 and completed a pain assessment in the medication administration record to identify residents who had unreported complaints of pain. No other residents had complaints of pain that were not conveyed to the charge nurse. No other residents were affected by the facility practice.