Failure to Provide Required CPAP Therapy for Resident with Sleep Apnea and CHF
Penalty
Summary
Facility staff failed to provide necessary respiratory care for a resident who required CPAP therapy following a hospital stay for acute respiratory failure secondary to congestive heart failure and obstructive sleep apnea. The hospital discharge summary specified the need for CPAP at night, but a review of the resident's clinical record showed no evidence that CPAP therapy was initiated during the resident's stay. Progress notes indicated that staff communicated with a nurse practitioner regarding the placement of a BiPAP device, and a respiratory therapist was notified to set up the machine, but there was no documentation that the CPAP was ever provided. Interviews with staff revealed that the admitting nurse is responsible for verifying CPAP orders with the physician and informing them if the facility does not have a CPAP machine available. Staff also stated that it is the facility's responsibility to provide a CPAP device if the resident is unable to bring their own from home. Despite these procedures, the facility did not provide the required CPAP therapy, and no policy or additional information regarding CPAP provision was supplied when requested by surveyors.