Failure to Clean and Document CPAP/BiPAP/AVAP Equipment per Orders and Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure CPAP/BiPAP/AVAP equipment was cleaned according to physician orders and the facility’s CPAP/BiPAP Cleaning policy for three residents using respiratory support devices. The policy, revised 6/11/25, required daily cleaning of mask frames after use with CPAP cleaning wipes or soap and water, with proper drying and storage, in accordance with CDC guidelines and manufacturer recommendations. For one resident with paraplegia and obstructive sleep apnea, the medical record showed an AVAP order to clean the mask daily starting 12/14/23, but the December 2025 Treatment Administration Record (TAR) did not contain an order to clean the AVAP mask on 12/4/25. This resident, who was cognitively intact and responsible for their own healthcare decisions, reported that lack of AVAP mask cleaning, along with staff popping a pimple, started irritation on the face, and was diagnosed with facial cellulitis on 12/15/25. A second resident with obesity and obstructive sleep apnea had an order to clean the CPAP mask, headgear, and tubing with mild soap and warm water each morning every Friday for sleep apnea care, starting 12/14/24. This resident, also cognitively intact and responsible for their own healthcare decisions, reported the CPAP mask had been washed only once since admission. The March 2026 TAR showed CPAP cleaning entries marked with a “4” on two dates, indicating a nursing progress note should explain why the treatment was not completed, but no such progress notes were found in the medical record, as confirmed by the DON. A third resident with acute and chronic respiratory failure with hypoxia and an activated POA for healthcare had an order to clean the BiPAP mask once daily starting 2/14/26; this resident was unsure if staff cleaned the mask daily, and the March 2026 TAR lacked documentation of BiPAP cleaning on one date. An LPN stated nurses were responsible for cleaning CPAP/BiPAP/AVAP masks and documenting this in the TAR, and the DON confirmed that masks should be cleaned daily, tubing weekly, and that there were missing dates of completion for all three residents.
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