Failure to Replace CPAP Filter According to Manufacturer Guidelines
Penalty
Summary
The facility failed to provide appropriate respiratory care services for one resident with obstructive sleep apnea who required nightly use of a CPAP machine. The resident's care plan and physician's order specified the use of the CPAP machine at bedtime. During multiple observations and interviews, it was found that the filter in the resident's CPAP machine was discolored, appearing light grey and dark grey, rather than the white color of a new filter. Staff, including a licensed vocational nurse, the assistant director of nursing, and the respiratory therapy supervisor, acknowledged the filter's condition and were unsure who was responsible for checking or replacing it. A review of the manufacturer's user guide indicated that the CPAP filter should be checked and replaced at least every six months, or more frequently if dirty or blocked. However, there was no documentation that the filter had been inspected or changed for this resident. The director of nursing confirmed that nursing staff were responsible for ensuring the CPAP machine was functioning and that the respiratory department was responsible for settings, but acknowledged the facility did not follow the manufacturer's guidelines for filter replacement.