Failure to Document CPAP Settings in Physician Orders
Penalty
Summary
The facility failed to ensure that respiratory equipment settings for a resident with obstructive sleep apnea were obtained and accurately reflected in the physician's orders. The resident, who was cognitively intact, was using a CPAP machine as part of their treatment. The admission Minimum Data Set (MDS) did not indicate the use of CPAP, and the initial physician's order specified only the times for the CPAP to be turned on and off, without including the required machine settings. During observation, the CPAP machine was present at the bedside, but a review of the clinical record and facility policy revealed that the necessary settings were missing from the physician's order. Facility staff were unable to explain why the settings had not been obtained and documented as required by policy. The facility's policy stated that physician orders for CPAP should include the settings, oxygen flow rate if used, and the time period for use, but this was not followed in the resident's case.