Failure to Obtain CPAP Order After Hospital Readmission for Respiratory Failure
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a physician’s recommended respiratory treatment, specifically a CPAP, was ordered and implemented for a resident readmitted from the hospital. The facility’s policy on General Physician Services states that the attending physician is responsible for managing the resident’s medical care and that care is based on the physician’s orders, including treatments and services. The resident was admitted with diagnoses of acute and chronic respiratory failure with hypoxia, obstructive sleep apnea, and obesity, and was dependent on staff for ADLs but cognitively intact with a BIMS score of 15/15. Nursing documentation shortly after admission noted diminished lung sounds bilaterally and that the resident preferred the head of the bed elevated to avoid shortness of breath, though no shortness of breath or need for supplemental oxygen was recorded at that time. The facility physician documented that the resident had presented to the ED with shortness of breath, was severely hypoxic, required BIPAP and aggressive diuresis, and was later transitioned to nasal cannula. In that same note, the physician concluded that the resident needed follow-up with pulmonary for possible PFT and possible CPAP. The resident’s care plan identified altered respiratory status related to respiratory failure and obstructive sleep apnea and directed staff to report abnormal findings to medical providers and monitor vitals. During interviews, the physician stated that, after reviewing the medical record and communicating with nursing staff, he informed nursing that the resident required a pulmonary test and a CPAP, and acknowledged that an order for CPAP should have been issued. The DON also stated there was miscommunication regarding the order and that the physician did not write it, despite facility policy requiring physician orders to be addressed in a timely manner. The resident’s cause of death was documented as congestive heart failure.
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