Failure to Replace and Maintain BiPAP Equipment per Policy
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to replace and maintain respiratory equipment for a resident using a BiPAP machine. Facility policy dated 02/25/2026 required routine replacement of BiPAP components to prevent infection, specifying that the face mask and tubing be replaced every three months and the headgear, non-disposable filters, and humidifier every six months. A diagnostics and consultants document for the resident also specified replacement intervals for the water chamber, tubing, and face mask. The resident, admitted with obstructive sleep apnea and with a provider order for nightly BiPAP use, reported using the BiPAP every night and relying on staff for care and maintenance of the equipment. The resident stated that the mask in use was the same one received at the initial equipment appointment and, to their knowledge, had never been changed. During multiple observations over three days, surveyors saw the resident’s BiPAP mask and tubing lying on the bed, with the mask lodged between the mattress and a quarter side rail on two occasions, and noted the mask appeared cloudy with dried white spots. In interviews, an LPN stated that central supply was responsible for managing and changing residents’ respiratory equipment and determining replacement frequency. The central supply staff member reported being unaware that the resident used a BiPAP and confirmed they had not ordered or changed any respiratory supplies for this resident. The DON confirmed that the resident’s respiratory equipment had not been changed according to facility policy or the provider’s recommendations documented on the diagnostics and consultants form.
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