Failure to Ensure Properly Fitting CPAP Masks and Provision of Ordered Therapy
Penalty
Summary
The facility failed to ensure that prescribed CPAP therapy was effectively provided by not securing properly fitting masks for two residents with orders for nighttime CPAP use. One resident with obstructive sleep apnea had a physician order for CPAP at night, but the CPAP machine and mask at bedside appeared clean and unused. The resident reported not using the CPAP for months because the mask did not fit, leaked air, and blew into his eyes, and stated he had informed nursing staff and a pulmonary NP of the problem. Documentation showed that a NP noted the resident’s complaint of an ill-fitting mask and referred him for refitting, and a subsequent pulmonary NP note recorded the resident’s request for a new mask and that facility staff were notified he needed one. A later health status note documented that the resident still had not received a new mask, and facility nursing staff again notified the pulmonary NP. The pulmonary NP stated the resident required CPAP at night and that she was not informed until a later date that the mask did not fit, and explained that a poorly fitting CPAP or BiPAP mask can result in the resident not receiving enough oxygen during sleep, potentially leading to respiratory distress and/or failure. Another resident with COPD had an order for CPAP at night but had her CPAP machine, tubing, and mask wrapped in a plastic bag on the bedside table. She reported not using the CPAP for a long time because the mask was too big and stated she had been waiting for pulmonology to refit her mask despite repeatedly asking when they would come. A pulmonary NP note documented that the resident requested replacement of her medium-sized mask with a small one and that facility staff were notified. A subsequent NP note recorded that the resident complained of an ill-fitting CPAP mask, was not using CPAP at night, and had lost approximately 50 pounds since the mask was first fitted, with an order for pulmonary NP evaluation for refitting. The pulmonary NP stated she had notified facility nursing staff that the resident needed a small mask so it could be ordered and that once ordered, a mask should arrive within a couple of weeks. A RN reported that both residents had been waiting at least a month for pulmonary to come fit them for CPAP masks, that their masks were too big so they did not use CPAP, and that she had called pulmonary twice without receiving a return call. The DON stated she was not aware that either resident needed new CPAP masks, despite the facility’s noninvasive ventilation policy stating that equipment should be replaced immediately when broken or malfunctioning.
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