Failure to Obtain Physician Order for Respiratory Device
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident diagnosed with obstructive sleep apnea and asthma. Observations revealed the presence of a CPAP or BiPAP machine at the resident's bedside, but there was no physician order for either device in the resident's clinical record since their admission. Despite documentation in nursing progress notes indicating the resident's use of CPAP and BiPAP on multiple occasions, the necessary physician order was absent. The resident's care plan included the use of CPAP at bedtime per order, but the facility's records did not reflect an actual physician order for the device. An email from the Nursing Home Administrator confirmed that the resident used a BiPAP, not a CPAP, and acknowledged the lack of a physician order prior to the surveyor's inquiry. This oversight indicates a failure to adhere to the facility's policy and professional standards of practice regarding respiratory care.
Plan Of Correction
1. Resident 44 had orders revised to reflect BiPAP use. 2. An initial audit of residents who use BiPAPs was conducted to ensure accuracy with physician orders. 3. Education was completed with licensed nursing staff on ensuring that orders for BiPAPs are completed. 4. 2 new admissions will be audited for BiPAP orders weekly x 4, then monthly x 2 by DON or designee. Results of this audit will be presented to the QAA committee for review. 5. The facility will be in substantial compliance by 1/7/25.