Failure to Document CPAP Settings in Physician Orders
Penalty
Summary
For two out of three residents reviewed for respiratory care, the facility failed to include the required CPAP machine settings in the physician orders. One resident was admitted with a diagnosis of obstructive sleep apnea and had an order for CPAP use at bedtime and removal in the morning, but the specific machine settings were not documented in the order. Similarly, another resident with obstructive sleep apnea had an order for CPAP use at night and removal in the morning, but again, the settings were not specified. Interviews with facility staff, including the respiratory therapist and the Director of Nursing, confirmed that the CPAP orders for both residents lacked the necessary settings, despite the residents bringing their own machines from home.