Failure to Document and Care Plan CPAP Use for Resident
Penalty
Summary
Facility staff failed to provide safe and appropriate respiratory care for a resident who required nightly use of a continuous positive airway pressure (CPAP) machine. The resident, who had diagnoses including renal insufficiency, diabetes, and anemia, reported using a CPAP nightly. Observations confirmed the presence of a CPAP machine at the bedside, and a faxed physician's order for the device was present. However, the facility did not enter the CPAP order or its settings into the electronic chart, and the resident's care plan did not reflect the use of the CPAP machine. The Minimum Data Set (MDS) assessment also failed to indicate the resident's use of a non-invasive mechanical ventilator. Interviews with facility staff revealed that the omission occurred during a transition of responsibility from the Director of Nursing (DON) to the MDS Coordinator. Both the MDS Coordinator and the DON confirmed that the CPAP order and care plan documentation were missing. The facility's policy required provider orders for respiratory devices to be recorded and included in the care plan, but these steps were not followed for this resident.