Failure to Provide Physician Orders and Proper Maintenance for CPAP Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for three residents who required the use of continuous positive airway pressure (CPAP) machines. All three residents had medical conditions such as chronic obstructive pulmonary disease (COPD), pulmonary fibrosis, obstructive sleep apnea, mesothelioma of the pleura, and respiratory failure, which necessitated the use of CPAP therapy. Despite these needs, the facility did not obtain or document physician's orders for the use, cleaning, or maintenance of the CPAP machines upon the residents' admission, as required by facility policy. Observations and interviews revealed that the residents were using CPAP machines without proper physician orders in place. One resident reported using their CPAP machine at night with settings from home and cleaning it independently, while another required staff assistance for cleaning and mask application but did not receive it. The surveyor observed that the CPAP equipment for two residents was visibly dirty, with masks and tubing containing skin particles, hair, dirt, and oil, and residents confirmed that staff had not cleaned the machines since admission. The facility's policy required verification of physician orders and regular cleaning and maintenance of CPAP equipment, including mask, tubing, and filters. However, the lack of timely physician orders and failure to assist residents with cleaning and maintaining their CPAP machines resulted in noncompliance with these requirements. Staff and leadership acknowledged during interviews that orders should have been obtained and cleaning performed as per policy, but these actions were not completed prior to the surveyor's findings.