Failure to Obtain Physician Orders and Monitor C-PAP/BI-PAP Use
Penalty
Summary
The facility failed to obtain physician orders for the use and cleaning of Continuous Positive Airway Pressure (C-PAP) and Bilevel Positive Airway Pressure (BI-PAP) machines for four residents. In each case, the residents were using their own C-PAP or BI-PAP machines, which were brought from home, but there were no corresponding physician orders documented in their medical records. Additionally, the facility did not document orders for the cleaning, monitoring, or settings of these machines, despite the residents' ongoing use and medical needs. The facility also failed to consistently monitor and document vital signs, including oxygen saturation and respirations, for three residents using C-PAP/BI-PAP machines. Medical records showed significant gaps in the documentation of these vital signs, and interviews with residents and family members confirmed that staff were not regularly obtaining or recording this information. Some residents and their families reported that staff did not assist with cleaning the machines or checking the settings, and in some cases, family members or the residents themselves were responsible for these tasks. Observations revealed that C-PAP and BI-PAP machines and their components, such as tubing and masks, were not stored in a sanitary manner, with equipment left uncovered and in direct contact with surfaces. Staff interviews confirmed a lack of oversight regarding the management of these devices, and the facility's own policy required physician orders, regular monitoring, and cleaning by licensed nurses, none of which were consistently followed. The absence of a respiratory therapist and lack of staff involvement in managing the machines further contributed to the deficiency.