Failure to Update Care Plan for New CPAP Order
Penalty
Summary
The facility failed to develop and revise a comprehensive care plan in accordance with physician orders and professional standards for one resident who required respiratory equipment. Specifically, after a new physician order was issued for an auto-adjusting CPAP machine with a pressure range of 8-18 cm H2O and modem setup, the facility did not update the resident's care plan to reflect this change. The care plan continued to reference an outdated CPAP setting of 4 cm H2O, and there was no documentation that the interdisciplinary team reviewed or implemented updated interventions related to the new therapy. Record reviews confirmed that the resident, who had a history of bipolar disorder and moderate cognitive impairment, received the new CPAP machine but the care plan was not updated accordingly. Interviews with the LPN/MDS Coordinator, DON, and Administrator all confirmed that the new physician order was not incorporated into the care plan and that the interdisciplinary team did not review or revise the plan to address the resident's updated respiratory needs.