Failure to Document CPAP Use on MDS Assessment
Penalty
Summary
The facility failed to accurately document a resident's use of a continuous positive airway pressure (CPAP) device on the comprehensive Minimum Data Set (MDS) assessment. The resident, who had a history of acquired absence of the right foot, sacral pressure ulcer, hematogenous osteomyelitis, lack of coordination, muscle weakness, and anxiety, was admitted with multiple care needs and required significant assistance with activities of daily living. The MDS assessment did not indicate the resident's need for a CPAP, despite the resident's medical record and staff interview confirming its use. Further review of the resident's care plan and Care Area Assessment (CAA) showed no mention of the CPAP device, even though the resident was dependent on staff for most care and had complex medical conditions. The facility's comprehensive assessment policy required accurate and timely assessments reflective of the resident's status, but this was not met in the case of the CPAP documentation. An administrative nurse confirmed that all CPAPs should be indicated on the MDS, highlighting the omission.