Failure to Clean and Document CPAP Equipment Maintenance
Penalty
Summary
The facility failed to ensure proper cleaning of a resident's CPAP equipment and mask as recommended by facility policy. The resident, who had diagnoses including COPD, obstructive sleep apnea, diabetes, and hypertension, used a BiPap with oxygen every night. The care plan did not include interventions related to cleaning respiratory equipment, and there were no physician orders or documentation in the Treatment Administration Record regarding cleaning of the CPAP equipment or mask. Nursing notes also lacked any mention of cleaning, and multiple observations confirmed that the equipment and mask were not cleaned. Interviews with nursing staff revealed confusion and lack of clarity regarding responsibility for cleaning the CPAP equipment, with no official cleaning schedule or documentation in place. The Director of Nursing confirmed that the facility did not have a system for cleaning or documenting the cleaning of CPAP equipment and masks. The facility's policy required weekly cleaning of the equipment, but this was not followed, and the resident expressed concern about the cleanliness of her equipment and the risk of infection.
Plan Of Correction
Resident #10 was immediately assessed and found to have no adverse effects. All residents with orders for a CPAP have the ability to be effected. Resident #10 CPAP was immediately cleaned by respiratory nurse. All CPAPs were immediately audited by respiratory nurse to ensure proper cleaning. Education was provided to respiratory nursing by DON on 5/22/25 regarding CPAP cleaning policy. DON/Designee to complete weekly audits to ensure all CPAPs are cleaned per policy for 4 weeks to ensure compliance. Results to be reviewed in QAPI.