Failure to Obtain Timely Orders for CPAP Use
Penalty
Summary
The facility failed to obtain timely physician orders for the use of a non-invasive mechanical ventilator (CPAP) for a resident with a history of chronic diastolic congestive heart failure. Upon admission, the resident's hospital discharge records indicated the need to continue CPAP therapy, but there was no evidence of a physician order for the CPAP machine from the time of admission until several weeks later. The resident's care plan and Minimum Data Set did not reflect the use of a CPAP machine, and the medication and treatment administration records showed no related orders during this period. Observations revealed the presence of a CPAP machine in the resident's room, and the resident reported using the device for years, though not in the days prior to the survey. Nursing staff were unaware of the absence of orders for the CPAP and did not consistently monitor or assist with its use. The DON confirmed that orders for CPAP use, including settings and equipment care, were required but had not been obtained at admission. The administrator acknowledged the need for communication among staff and medical providers to confirm respiratory equipment orders.