Missing Physician Order for CPAP Machine
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident who was using a continuous positive airway pressure (CPAP) machine. Record reviews showed that while the resident's care plan, progress notes, and hospital discharge summary all referenced the use of a CPAP machine at night, there was no corresponding physician order for this treatment in the monthly physician orders for the relevant period. The resident's face sheet and Minimum Data Set (MDS) assessments also documented the use of the CPAP machine, and direct observation confirmed the presence of the device at the bedside. Interviews with nursing staff confirmed the resident's use of the CPAP machine, but staff were unaware of why the physician order was missing from the records. The Director of Nursing (DON) acknowledged that the omission may have occurred during the resident's discharge and subsequent re-admission, resulting in the physician order not being reactivated. The facility's policy requires that all drug and biological orders be recorded on the physician's order sheet in the resident's chart, but this was not done for the CPAP machine. The deficiency was identified through observation, interview, and record review, which collectively demonstrated that the facility did not ensure the resident's medical record was complete and accurately documented regarding the use of the CPAP machine.