Failure to Include C-PAP Use in Baseline Care Plan
Penalty
Summary
Facility staff failed to develop a baseline care plan addressing the use of a C-PAP machine for one resident within 48 hours of admission. The resident was admitted with a diagnosis that included sleep apnea and was documented as cognitively intact and oriented. The admission assessment and nurse's notes confirmed the resident's use of a C-PAP machine, and the device was observed in the resident's room. However, review of the baseline care plan did not show any documentation regarding the C-PAP use. Staff interviews confirmed that the purpose of the care plan is to ensure all staff are informed about the resident's care needs, and that the C-PAP should have been included. Administrative staff were made aware of the omission during the survey, but no additional information was provided prior to the survey team's exit.