Failure to Ensure Proper Cleaning and Documentation of CPAP Equipment
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory services in accordance with professional standards of practice for a resident who required use of a CPAP machine for obstructive sleep apnea. The resident’s MDS documented moderate cognitive impairment with a BIMS score of 12 and a diagnosis of obstructive sleep apnea. The resident reported that no facility staff had ever cleaned her CPAP machine or mask since admission. Observation of the CPAP equipment showed speckled white sediment on the outside of the machine, discolored water in the reservoir, and cloudy white sediment and film on the inside of the mask, along with dry red material on areas of the mask. Review of the resident’s care plan revealed no documentation that the resident was responsible for cleaning her own CPAP machine or mask. The TAR contained no orders for staff to clean the CPAP machine or mask. Multiple nursing staff, including RNs and an LPN, stated they had never cleaned the resident’s CPAP equipment and believed the resident cleaned it herself, while also acknowledging that such responsibility should have been documented in the care plan and/or TAR if the resident were to perform this task. The DON stated the resident had told her she would clean her own CPAP and did not need staff help, but acknowledged that the care plan and TAR did not reflect this. Facility policy on CPAP and nebulizer cleaning required equipment to be cleaned and disinfected according to manufacturer instructions and maintained and documented per CMS and the facility’s Infection Prevention and Control Program, which was not followed in this case.
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