Failure to Assess and Provide CPAP Therapy for Resident with OSA
Penalty
Summary
The facility failed to assess and verify a resident's history of obstructive sleep apnea (OSA) and did not coordinate necessary CPAP therapy with the physician. The resident, who had a documented history of OSA and had used CPAP for 20 years, reported to staff that she was not allowed to use her CPAP machine in the facility. The resident also stated she typically slept in a sitting position and had informed both social services and nursing staff of her CPAP use. Review of the resident's hospital records confirmed a diagnosis of OSA and CPAP use, but there was no documentation in the facility's records that a CPAP machine was provided or that the need for CPAP therapy was verified. Interviews with facility staff revealed that the diagnosis of OSA was missed during the comprehensive assessment, and there was no care plan addressing sleep apnea. The DON confirmed there was no documented diagnosis or care plan for sleep apnea, and the resident was not placed on a CPAP machine. The MDS nurse acknowledged the oversight in reviewing the resident's medical history, and the ADON stated that the diagnosis should have been verified with the physician and included in the care plan. Facility policy indicated that CPAP should be used to improve oxygenation in residents with OSA, but this was not followed in the resident's case.