Failure to Timely Transcribe and Provide Ordered C-Pap Equipment
Penalty
Summary
The facility failed to ensure that services were provided and documented according to professional standards for one resident who required a new Continuous Positive Airway Pressure (C-Pap) machine. A physician's order for a new C-Pap machine was issued on 1/31/25 following a sleep study, but the order was not transcribed or acted upon until nearly four months later. The facility's policy requires that physician orders be transcribed and followed as written, with clarification obtained when needed. However, the order for the new C-Pap machine was not entered, and the resident did not receive the prescribed equipment until 5/28/25. The resident involved had a history of bipolar disorder and was assessed as moderately cognitively impaired. Documentation showed that the resident was only fitted for and received the C-Pap machine after a significant delay. Interviews with the DON and Administrator confirmed that the order was known to facility leadership shortly after it was written, but authorization to obtain the equipment was not given until months later. The nurse practitioner also confirmed the importance of timely provision of the C-Pap machine as ordered by the pulmonologist.