Failure to Obtain Physician Order and Care Plan for CPAP Therapy
Penalty
Summary
The facility failed to obtain a physician's order for CPAP (Continuous Positive Airway Pressure) therapy and did not develop or implement a care plan for its use for one resident. Record review showed that the resident had multiple diagnoses and was cognitively intact, as indicated by a Brief Interview of Mental Status score of 15. The Minimum Data Set assessment did not document CPAP use, and the resident's care plan lacked goals, plans, and interventions related to CPAP. Observations on multiple occasions revealed a CPAP machine and tubing at the resident's bedside, and the resident confirmed daily use of the device. The physician's order for CPAP was only obtained on the last day of the survey after surveyor intervention.
Plan Of Correction
On , additional CPAP orders were obtained for Resident # 304. On , the care plan for a CPAP was revised by the Regional Nurse Consultant. On , the DON conducted a quality review of current residents who require the use of a CPAP to ensure proper physician orders and care plans were in place. No additional findings were noted. By , licensed nurses were educated by the staff development coordinator on the components of F695 with an emphasis on obtaining appropriate physician orders for use of a CPAP as well as implementing a care plan for the CPAP. As part of a systematic change, newly hired licensed nurses will be educated on the components of F695 with an emphasis on obtaining appropriate physician orders for use of a CPAP as well as implementing a care plan for the CPAP during orientation. The DON/Designee will conduct quality monitoring of 3 residents who require CPAPs weekly x 4 weeks and 5 residents who require CPAPs monthly x 2 months to ensure that proper physician orders and care plans are in place. The findings of these quality monitoring to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.