Failure to Apply Ordered Auto-PAP for Resident with Respiratory Conditions
Penalty
Summary
The facility failed to apply an Automatic Positive Airway Pressure (auto-PAP) machine as ordered for a resident with significant respiratory conditions, including respiratory failure, COPD, obesity, and emphysema. The physician's order required the auto-PAP to be applied every night and as needed for naps. Documentation showed the treatment was not administered on a specific night, and the responsible LPN admitted to forgetting to apply the device, without providing a specific reason. The resident's medical record indicated a history of severe respiratory issues and multiple recent hospitalizations for respiratory failure. On the morning following the missed treatment, the resident was initially alert and eating breakfast but was later found to be in respiratory distress after a call from her daughter. The assigned RN assessed the resident, applied the auto-PAP, and arranged for emergency transfer to the hospital. The night nurse did not communicate the missed treatment to the day staff. The incident was self-reported by the facility, and staff interviews confirmed the lapse in following the treatment order for the auto-PAP application.