Failure to Obtain Physician Orders for CPAP Maintenance
Penalty
Summary
The facility failed to obtain physician's orders for the weekly cleaning and tubing changes of a resident's CPAP machine, as well as for the daily filling of the CPAP machine's chamber with distilled water, from March 2025 through the resident's discharge. The deficiency was identified through interviews and record reviews, which revealed that although the facility's staff, including the Infection Preventionist and Unit Manager, stated that these tasks were performed by the night shift nurses, there were no corresponding physician's orders or documentation in the resident's medical record. The Medication Administration Records showed daily administration of the CPAP machine but did not include documentation for cleaning, tubing changes, or water chamber maintenance. The resident involved had multiple medical conditions, including obstructive sleep apnea, multiple rib fractures, a prosthetic heart valve, depression, and a history of falls, and required assistance with all activities of daily living. Interviews with the Unit Manager and Director of Nursing confirmed that physician's orders were required for CPAP maintenance tasks, but none were present in the record. The facility's policy also indicated that such procedures should be performed according to physician's orders and manufacturer instructions, but this was not followed in practice for the resident in question.