Failure to Ensure Orders and Proper Care for CPAP Equipment
Penalty
Summary
The facility failed to ensure that a resident with a history of pulmonary embolism, obstructive sleep apnea, and other respiratory conditions had appropriate physician orders in place for the use of a CPAP machine upon admission. Review of the resident's records showed that there were no CPAP orders documented from the time of admission until several weeks later, despite the resident's need for this respiratory support. Additionally, the care plan did not include specific CPAP settings or instructions for CPAP care, and there was no evidence that the CPAP was being properly cared for during this period. Observations revealed that the CPAP equipment was not consistently stored in a sanitary manner, with the mask left unbagged on the bedside table. The resident reported that staff typically left the CPAP on the table and only recently began placing it in a bag. The facility's policy required daily cleaning and proper storage of CPAP equipment, but there was no documentation or evidence that these procedures were followed prior to the addition of new treatment orders. The DON confirmed that orders should be entered upon admission and that staff are expected to follow facility policy for cleaning and storage.