Failure to Develop and Implement Care Plan for CPAP/BIPAP Use
Penalty
Summary
The facility failed to develop and implement a patient-centered care plan for a resident who was admitted with a diagnosis of obstructive sleep apnea and required the use of a CPAP/BIPAP machine. Upon observation and interview, it was found that the resident was using a BIPAP machine at the bedside and was responsible for cleaning and maintaining the device herself. However, a review of the electronic medical record by a licensed nurse confirmed that there was no care plan in place addressing the use of the CPAP/BIPAP machine. Further interviews with facility staff, including the Minimum Data Set Nurse and the Director of Nursing, revealed that the resident's hospital history documented the need for a CPAP machine, but no care plan was created until several days after admission. The facility's own policy required the interdisciplinary team to develop a comprehensive, person-centered care plan to address each resident's medical and nursing needs, which was not followed in this case.