Failure to Develop Care Plan for OSA and BiPAP Use
Penalty
Summary
The facility failed to develop a care plan addressing obstructive sleep apnea (OSA) for a resident who was admitted with multiple diagnoses, including OSA, heart failure, cellulitis, muscle weakness, morbid obesity, and hypertension. The resident's hospital history indicated she experienced hypercapnic respiratory failure secondary to Obesity Hypoventilation Syndrome and OSA, which was treated with BiPAP therapy, resulting in improvement. Despite these significant medical issues, a review of the resident's care plans confirmed that no care plan was created for OSA or the use of BiPAP. The resident was assessed as having intact cognition but required staff assistance for bed mobility, bathing, dressing, personal hygiene, and supervision for eating and oral hygiene. During an interview and record review, the ADON verified the absence of a care plan for OSA or BiPAP and acknowledged that this could impact the resident's overall health. The facility's own policy requires the interdisciplinary team to develop and implement a comprehensive, person-centered care plan for each resident, including measurable objectives and timeframes to address all identified needs, but this was not done for the resident's OSA.