Lack of Staff Training and Competency in CPAP Device Management
Penalty
Summary
The facility failed to ensure that direct-care staff were trained and competent in the daily use of a resident's CPAP (Continuous Positive Airway Pressure) machine, which is necessary for the resident's well-being and safety. The resident, who had moderate cognitive impairment and multiple medical diagnoses including atrial fibrillation and chronic kidney disease, relied on a CPAP device for non-invasive mechanical ventilation. Observations and interviews revealed that the resident's significant other primarily managed and maintained the CPAP device, with staff involvement limited to turning the device on. The resident expressed uncertainty about staff knowledge regarding the device and reported having to question staff about their competency before allowing them to handle it. Nursing staff and the DON confirmed that there was no formal training provided on the use or troubleshooting of CPAP devices, and no user manual was readily available. Staff described relying on informal methods, such as calling the resident's significant other or searching online, to resolve issues with the device. Documentation showed that while there was a nursing order to clean the CPAP daily, there was no information on device settings or troubleshooting procedures. The facility's policy stated that only qualified and properly trained staff should administer oxygen through a CPAP mask, but did not specify how such training or competency would be ensured. The lack of structured training and clear guidance led to staff uncertainty and inconsistent management of the resident's CPAP device.