Failure to Properly Store CPAP Equipment According to Infection Control Policy
Penalty
Summary
Facility staff failed to provide respiratory care according to professional standards of practice for a resident who required CPAP therapy. Multiple observations over three consecutive days revealed that the CPAP machine, including its tubing and mask, was left uncovered and open to air on the resident's bedside table when not in use. This was in direct contradiction to the facility's own policy, which required that CPAP and BiPAP masks be stored within a plastic bag when not in use, with the bag changed weekly or as needed. The resident involved had a complex medical history, including aphasia following cerebral infarction, chronic kidney disease stage two, type two diabetes, Barrett's esophagus, nontraumatic subarachnoid hemorrhage, a history of cerebral infarction, and coronary atherosclerosis due to lipid plaque. The resident was assessed as having moderate cognitive impairment and required assistance with all activities of daily living, using a wheelchair for mobility. Despite physician orders for nightly CPAP use, staff did not follow infection control protocols for storing the equipment, as documented in the facility's policy.