Failure to Maintain Bipap Machine Water Chamber as Ordered
Penalty
Summary
A deficiency was identified when the facility failed to ensure proper maintenance of a bipap machine for a resident with acute and chronic respiratory failure, COPD, acute bronchospasms, and sleep apnea. The resident's provider orders specified that the bipap water chamber should be emptied, dried, and refilled with distilled water daily at bedtime. However, multiple observations over several days revealed that the water chamber remained partly full and was not emptied or dried between uses. The resident confirmed that staff were responsible for filling the chamber, but stated that no one had come to empty and rinse it out as required. Interviews with staff, including an LPN and the DON, confirmed that the expected practice was to empty and dry the bipap water chamber daily to help prevent possible infections. The resident's care plan did not address the care of oxygen and bipap equipment, and the facility was unable to provide a policy regarding respiratory equipment care when requested. These actions and omissions led to the failure to provide safe and appropriate respiratory care for the resident.