Failure to Ensure Functional CPAP and Accurate Documentation
Penalty
Summary
Facility staff failed to ensure that a resident's CPAP machine was functional and did not accurately document its use, despite provider orders and care plan interventions requiring nightly use and regular maintenance. The resident, who had diagnoses of heart failure, COPD, and obstructive sleep apnea, brought a non-working CPAP machine from home and reported to staff that it was not functioning. Staff informed the resident that they did not repair such equipment and did not assist in obtaining a replacement. Documentation in the Treatment Administration Record (TAR) and nursing progress notes indicated that the CPAP was being used and maintained, but provider notes contradicted this, stating the resident had not used the CPAP for over six months. Interviews with staff revealed that no one had initiated the process to obtain a replacement CPAP, and key personnel, including nursing and central supply, were unaware of the equipment's non-functionality. Staff responsible for respiratory care did not follow up on the resident's inability to use the CPAP, and discrepancies in documentation were acknowledged by facility leadership as a failure in practice. The lack of action and inaccurate documentation placed the resident at risk for health complications related to untreated sleep apnea.