Failure to Maintain and Replace CPAP Supplies for Residents
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care by not maintaining or replacing CPAP machines and supplies for all five residents reviewed who required respiratory treatments. Observations revealed that residents were using old or unclean CPAP masks, tubing, and water tanks, with some equipment showing visible signs of wear, discoloration, or contamination. Residents reported that they had not received new supplies since admission, and some had to clean their own equipment with tap water, while others stopped using their CPAP machines due to ill-fitting masks provided by the facility. Record reviews showed that care plans and physician orders did not include specific instructions or time frames for replacing CPAP supplies. In several cases, there were no orders for CPAP devices or supplies at all, and care plans lacked any focus on respiratory device use. Staff interviews indicated a lack of knowledge regarding the appropriate cleaning and replacement schedule for CPAP equipment, and the facility's policies did not specify time frames for exchanging supplies. The infection control policy referenced the need to prevent and control infections but did not address CPAP supply management. The third-party medical equipment company's replacement schedule recommended regular replacement of masks, tubing, and water chambers, but this guidance was not reflected in facility practice or policy. Interviews with clinical staff, including nurse practitioners and the infection control preventionist, confirmed that supplies should be exchanged according to manufacturer guidelines to reduce infection risk, but acknowledged that this was not being done. The administrator stated that supplies were only ordered when requested by residents or staff, and was unaware of recommended replacement intervals.