Failure to Store CPAP Mask in a Sanitary Manner
Penalty
Summary
The facility failed to ensure the continuous positive airway pressure (CPAP) mask for a resident was stored in a sanitary manner. The resident had multiple medical conditions, including an acquired absence of the right foot, pressure ulcer, osteomyelitis, muscle weakness, and moderately impaired cognition. The resident was dependent on staff for most activities of daily living and used a wheelchair. Despite the resident's complex medical needs, the care plan and electronic medical record did not include instructions for the use, cleaning, or sanitary storage of the CPAP device. During observation, the CPAP mask was found draped over the CPAP machine without a clean barrier or sanitary container. Interviews with nursing staff revealed inconsistent knowledge and practices regarding the proper storage of respiratory equipment, with some staff stating the mask should be placed in a plastic bag or drawer, and others indicating it was the responsibility of nursing staff to ensure sanitary storage. The facility did not have a respiratory storage policy available.