Failure to Obtain Orders for CPAP Use and Settings
Penalty
Summary
The facility failed to obtain appropriate physician orders for the use and settings of a CPAP machine for a resident with a diagnosis of obstructive sleep apnea. Upon admission, the resident brought a personal CPAP machine, but there were no orders from the hospital or admitting physician for its use or settings. Nursing documentation indicated awareness of the need for an order, and the resident reported not using the CPAP because it was not accessible or permitted without an order. The care plan addressed the resident’s respiratory status but did not include interventions for CPAP use. Attempts to obtain the necessary CPAP settings from the resident’s pulmonologist were minimal, with the Unit Manager making only one attempt to contact the pulmonologist and not following up further. The physician confirmed that settings needed to be ordered by a pulmonologist and that the resident was aware of his own settings, but facility policy required confirmation from a specialist. The resident and family both reported that the CPAP had been used consistently prior to admission, but during the facility stay, the machine was not used due to lack of orders. Throughout the resident’s stay, there was no documentation of CPAP use, and staff interviews confirmed that the absence of orders prevented its use. The resident was later discharged to the hospital for an unrelated acute kidney injury, but the deficiency centered on the facility’s failure to secure timely and appropriate orders for the resident’s CPAP therapy, resulting in the resident not receiving prescribed respiratory support during the stay.