Failure to Train Staff on CPAP Use and Maintenance
Penalty
Summary
Staff failed to maintain and monitor CPAP settings for a resident diagnosed with COPD, insomnia, and renal insufficiency, who used a non-invasive mechanical ventilator. The resident's CPAP machine was observed on the bedside table, and a family member reported concerns that staff were not knowledgeable about the device, leading her to take the machine to the home supplier to verify its settings. The family member also stated that no staff assisted with the CPAP, and that the receptionist, rather than clinical staff, had to help with the device on two occasions because no one else knew how to operate it. Interviews confirmed that the receptionist assisted the resident with the CPAP due to a lack of trained staff, and the DON acknowledged that the facility did not have staff trained in CPAP use or a respiratory therapist available for consultation. The DON stated that only a respiratory therapist should monitor CPAP settings, but the facility did not have one accessible, resulting in unqualified personnel providing assistance with the resident's CPAP machine.