Failure to Provide Prescribed Respiratory Care and Document Therapy Refusals
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral palsy, spastic quadriplegic cerebral palsy, muscle weakness, and dysphagia, who was dependent on staff for all activities of daily living, did not consistently receive prescribed respiratory care. The resident had a physician's order for an APAP (Automatic Positive Airway Pressure) machine to be applied at hour of sleep, as documented in the care plan and physician's orders. Despite this, internal device reports showed that the APAP machine was not used for 15 out of 29 days in October, with no documented refusals or explanations in the treatment records or progress notes for those days. Interviews with facility staff, including the unit supervisor, respiratory therapist, and DON, confirmed that the resident was supposed to use the APAP machine nightly and that nursing staff were responsible for applying the mask and turning on the device. Staff indicated that if the resident refused the therapy, it should have been documented, but there was no such documentation for the missed days. The responsible party for the resident was notified by the supply company about the lack of usage data and expressed concern, noting the resident's inability to apply the device independently due to limited mobility. The facility's policy required documentation of refusals and reasons for missed therapy, but this was not followed. The lack of APAP usage was confirmed by both internal device data and staff interviews, with no evidence that the resident refused the therapy or that staff made additional attempts to apply the device as required. The deficiency was identified through record review, interviews, and observation, demonstrating a failure to provide respiratory care and services consistent with professional standards of practice.