Failure to Provide Functioning CPAP Machine for Resident with Sleep Apnea
Penalty
Summary
A resident with a history of sleep apnea and obstructive sleep apnea was admitted with a physician's order for a continuous positive airway pressure (CPAP) machine to be used at bedtime. The resident's clinical record and interviews confirmed that the CPAP machine had been broken for over two months and had not been replaced, despite a documented order for replacement. The resident reported difficulty breathing at night and trouble sleeping due to the lack of a functioning CPAP machine. Observations confirmed that there was no CPAP or oxygen concentrator present in the resident's room during this period. Staff interviews, including with a CNA and a licensed nurse, verified the absence of a working CPAP machine and acknowledged that the issue had persisted for more than two months. The licensed nurse confirmed that the electronic medication administration record documented the CPAP as broken and missing parts throughout this time frame. No specific interventions were ordered to monitor the resident during sleep hours while awaiting the replacement machine. The facility's policy required that defective equipment be repaired or replaced, but this was not followed in the resident's case.