Failure to Maintain and Monitor CPAP Equipment and Settings
Penalty
Summary
The facility failed to provide staff with current CPAP machine settings and did not monitor or maintain CPAP mask and tubing needs for two residents. For one resident with diagnoses including COPD, CAD, and renal insufficiency, observations revealed that the CPAP machine was present at the bedside, but the resident had been using the same mask and tubing since admission, which were visibly worn and misshaped. The resident was unaware of the CPAP settings, and neither the clinical physician orders nor the care plan included the required CPAP settings. Chart review confirmed the absence of documentation regarding CPAP settings or supply changes, and the equipment supplier reported no supplies had been ordered since 2019. For another resident with COPD, insomnia, and renal insufficiency, similar deficiencies were observed. The resident and a family member reported that the same CPAP mask and tubing had been used for over a year, and the family member had to take the machine to the supplier to verify settings due to uncertainty about possible changes. The clinical orders and care plan also lacked CPAP settings, and there was no documentation of supply changes. The equipment supplier confirmed that no supplies had been ordered since the previous year, despite an established replacement schedule. Interviews with facility staff, including the DON, revealed a lack of awareness and procedures regarding the maintenance and replacement of CPAP supplies. The DON acknowledged that the facility is responsible for maintaining CPAP machines and that settings should be available to staff, but admitted to not having considered the supply replacement process. The facility's own policy requires physician orders to specify CPAP settings and mandates regular cleaning and replacement of equipment, which was not followed in these cases.