Failure to Maintain and Change CPAP Equipment per Manufacturer Guidelines
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required CPAP therapy, as staff did not change or clean CPAP equipment—including tubing, filters, and masks—in accordance with manufacturer recommendations and facility policy. For one resident with sleep apnea and COPD, observations revealed that the CPAP mask was left unbagged, and the tubing and mask had not been changed for over eight months, despite orders and policy requiring more frequent changes. Staff interviews confirmed a lack of clarity regarding responsibility for equipment maintenance, with some nurses unaware of when equipment was last changed or cleaned, and one nurse admitting to signing off on cleaning tasks that were not performed due to lack of supplies and resident sleep schedules. For another resident with COPD and obstructive sleep apnea, similar deficiencies were observed. The CPAP tubing and mask had not been changed for over eight months, and the resident reported that no staff had cleaned the equipment in months. Staff interviews indicated confusion about the cleaning schedule and a lack of a system to ensure equipment was changed every three months as required. The facility's policy and physician orders referenced following manufacturer guidelines, but did not specify timeframes, contributing to inconsistent practices. Review of facility policy and manufacturer guidelines confirmed that CPAP masks and tubing should be changed every three months, with filters changed more frequently. However, both direct observation and staff interviews demonstrated that these protocols were not followed, and documentation of cleaning or changing equipment was inaccurate. The lack of adherence to established schedules and unclear staff responsibilities led to the failure to maintain respiratory equipment as required.