Deficiencies in Infection Control: Improper CPAP Mask Storage and Inadequate Water Management Program
Penalty
Summary
The facility failed to ensure that a resident's continuous positive airway pressure (CPAP) mask was stored in a sanitary manner. During observation, the resident's unbagged CPAP mask was found resting directly on the bedside table, with no storage bag visible. The resident confirmed that the mask was usually not stored in a bag and that she did not have one for her CPAP mask. Interviews with staff revealed that the facility's practice was to store respiratory masks in dated bags when not in use, with the night shift responsible for ensuring bags were available and the day shift responsible for placing the mask in the bag. However, this protocol was not followed for the resident in question. Additionally, the facility failed to develop, implement, and maintain a comprehensive water management program to reduce the risk of Legionella and other waterborne pathogens. While documentation of Legionella testing and general monitoring instructions were available, they were not specific to the facility and lacked evidence of a risk assessment or ongoing monitoring to identify potential sources of Legionella growth. The maintenance staff was only aware of a single test conducted and did not have a detailed water management plan or diagram, indicating a lack of a systematic approach to water safety as required by facility policy.