Failure to Obtain Physician Orders and Provide Proper CPAP Care
Penalty
Summary
The facility failed to obtain physician orders for the use and care of a CPAP machine for a resident with severe cognitive impairment. The CPAP machine was observed in the resident's room, and the resident reported issues obtaining replacement parts and showed a dirty filter covered in debris. Despite the resident's ongoing use of the CPAP for at least five to six months, there were no active physician orders or care plan documentation regarding its use or maintenance. Staff interviews confirmed that the resident had been using the CPAP without corresponding physician orders or documentation on the Treatment Administration Record (TAR). The facility's policy requires verification of physician orders and regular cleaning and maintenance of CPAP equipment, including filter replacement according to manufacturer instructions. The user manual for the CPAP also specifies that the device should only be used as instructed by a physician and that filters should be checked and replaced regularly. However, these procedures were not followed, as evidenced by the lack of orders, care plan documentation, and the presence of a dirty filter. The Director of Nursing acknowledged that the facility was unaware of the resident's CPAP use until the day prior to the survey and that appropriate orders and care planning had not been completed.