Failure to Develop and Implement Care Plan for Sleep Apnea and BiPAP Use
Penalty
Summary
The facility failed to develop and implement a care plan addressing a resident's diagnosis of sleep apnea and the prescribed use of a BiPAP machine. The resident was admitted with diagnoses including diabetes mellitus and hypertension, and was assessed as having intact cognition and requiring moderate assistance with activities of daily living. The resident's physician had ordered nightly use of a BiPAP machine for sleep apnea, and the resident confirmed regular use of the device. However, upon review of the resident's clinical records and active care plans, it was found that no care plan had been created or initiated to address either the sleep apnea diagnosis or the use of the BiPAP machine. The Assistant Director of Nursing confirmed that care planning serves as a communication tool among staff to ensure consistent implementation of goals and interventions, including monitoring BiPAP use, resident education, and evaluation of tolerance. The absence of a care plan meant that staff lacked guidance on providing necessary care and services related to the resident's sleep apnea and BiPAP use. This deficiency was identified through observation, interview, and record review, and was found to be inconsistent with the facility's policy requiring comprehensive, person-centered care plans with measurable objectives and timelines.