Failure to Provide Physician-Ordered CPAP Therapy Due to Missing Equipment
Penalty
Summary
The facility failed to provide physician-ordered respiratory care for a resident who required nightly use of a CPAP machine. Upon admission, the resident's CPAP machine was missing necessary tubing, and documentation showed that the resident was unable to use the device as ordered. Despite repeated documentation in nursing progress notes and the electronic treatment administration record indicating the absence of the required part, the facility did not obtain the missing tubing for an extended period. The resident experienced multiple hospitalizations during this time, with all admission orders continuing to specify the need for nightly CPAP use. Interviews with facility staff confirmed that efforts to obtain the missing tubing were delayed, and the resident was unable to use the CPAP as ordered from the time of admission until the part was finally acquired. The Assistant Director of Nursing acknowledged that the facility contacted previous providers and suppliers but did not secure the necessary equipment until 50 days after the resident's initial admission. During this period, the resident had four hospital admissions related to hypoxia, and the lack of timely action by the facility directly resulted in the resident not receiving prescribed respiratory therapy.