Failure to Ensure Safe Use of CPAP Machine
Summary
The facility failed to provide safe and appropriate respiratory care for a resident using a home CPAP machine. The resident, who was admitted with diagnoses including COPD, asthma, and obstructive sleep apnea, did not have a physician's order for the use of the CPAP machine in the facility. Additionally, there was no assessment of the CPAP machine's integrity, no monitoring of the resident's respiratory condition or response to therapy, and no care plan that included interventions for CPAP therapy. Observations and interviews revealed that the resident's CPAP machine and mask had not been checked or cleaned according to the manufacturer's guidelines, which included daily cleaning of the mask and tubing. The resident confirmed that the mask and tubing had not been changed for several weeks. The facility's staff, including a registered nurse and a respiratory therapist, acknowledged the lack of a physician's order, assessment, and care plan for the CPAP machine, as well as the failure to clean the equipment as required. The Director of Nursing and the Infection Preventionist also confirmed these deficiencies, emphasizing the importance of having a physician's order, a care plan, and proper cleaning procedures to prevent respiratory infections. The facility's policies and procedures, as well as the CPAP machine's user manual, outlined the necessary steps for safe and effective use of the CPAP machine, which were not followed in this case.
Plan Of Correction
A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Resident 29's physician assessed the use of the CPAP machine and provided orders for its use and monitoring. The licensed nurse transcribed the physician order for the use and monitoring of Resident 29's CPAP machine on 2/26/2025. The Director of Maintenance evaluated the CPAP machine's safety and integrity on 2/26/2025. The licensed staff are monitoring Resident 29's use of CPAP machine daily and documenting the monitoring in the treatment administration record. The CPAP machine is cleaned routinely per manufacturer's guidelines by the Licensed Vocational Nurses. The IDT developed and initiated a care plan for the use of Resident 29's CPAP including interventions for assessment and monitoring of Resident 29's respiratory status and care of the CPAP machine on 2/26/2025. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken; Residents using home CPAP machines are potentially affected by the facility practice. The Assistant Director of Nursing audited all residents who use CPAP machines. A total of 3 residents use CPAP machines. 0 of 3 residents CPAP machines were brought from home. No other residents identified affected by the facility practice. The IDT audited care plans of residents who use a CPAP machine for respiratory conditions to ensure interventions including an assessment, physician order, monitoring and cleaning were present on 2/26/2025. C. What measures will be put into place or what systematic changes the facility make to ensure that the deficient practice does not recur; The Director of Nursing/designee will re-educate the nursing staff on or before 3/21/2025, re: the facility policy and procedures, Care Planning, with emphasis on residents with CPAP therapy must have person-centered interventions based on the assessment including evaluation of the safety and integrity of a CPAP machine, when brought from home, No Smoking sign at the resident's door, tubing and mask materials, routine evaluation of respiratory condition through pulse oximeter and routine cleaning per manufacturers guidelines for the CPAP machine. The Interdisciplinary Team will evaluate newly admitted residents for to identify residents with CPAP therapy to ensure the completion of an assessment, physician order and comprehensive person-centered care plan with interventions for CPAP therapy, routine cleaning of the mask and replacement of the tubing, and cleaning of the CPAP machine. Charge nurses will complete routine pulse oximetry each shift of residents with CPAP machines. D. How the facility plans to monitor its performance to make sure solutions are sustained; The Infection Prevention Nurse/designee will monitor residents who use CPAP therapy to ensure cleanliness of the mask, tubing and machine per manufacturer's guidelines to reduce the risk of residents developing respiratory infection. The Charge Nurse will monitor the residents' respiratory health, assess the resident's pulse oximetry and document in the medication administration record each shift. Concerns identified will be corrected at the time of observation and reported to the Director of Nursing. The Director of Nursing will monitor the licensed nurses' performance through observation and IPN reports; and provide re-education or progressive disciplinary action as indicated. The DON/designee will report trends identified in CPAP therapy to the Quality Assurance committee during the quarterly QA&A meeting for the purpose of process improvement changes to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025 --- F697 Pain Management CFR(s): 483.25(k) A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; The licensed nurse completed a pain assessment of Resident 65 to ensure current pain management program is effective on 2/24/2025. CNA 1 received 1:1 re-education on the facility procedure to report resident complaints of pain to the charge nurse for further evaluation on 2/24/2025. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken; Residents cared for by certified nurse assistant 1 are potentially affected. The Charge Nurse interviewed residents cared for by CNA 1 on 2/24/2025 and completed a pain assessment in the medication administration record to identify residents who had unreported complaints of pain. No other residents had complaints of pain that were not conveyed to the charge nurse. No other residents were affected by the facility practice.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident who required oxygen therapy for SOB had an oxygen bubbler that was overdue for replacement, despite a TAR directing weekly changes of oxygen supplies including the bubbler and tubing. Staff confirmed the bubbler should have been changed weekly, and the DON and staff educator stated nurses were expected to follow the provider order as written and that all disposable oxygen pieces were to be changed weekly.
A resident with COPD, acute respiratory failure with hypercapnia, and oxygen dependence was admitted with prior records showing nightly Bi-pap use and specific settings, but the facility did not have a Bi-pap order or settings in the chart and the baseline care plan did not address oxygen or Bi-pap. The resident reported he went without Bi-pap for three nights because a connector piece was missing, while the hospice RN, admitting LPN, ADON, and DON each stated they were unaware of the machine or did not verify the equipment and orders at admission.
Respiratory care was not provided as ordered for one resident receiving O2, as the NC tubing was not dated. Tracheostomy care was also not provided as ordered for another resident: heavy thick mucus was visible under the trach, the ATM mask was soiled with mucus, the ATM and nebulizer tubing were not dated or stored in a bag, and the suction catheter tubing end was not stored in a bag. An RN confirmed the findings.
The facility failed to follow physician orders for oxygen equipment for two residents with COPD-related diagnoses. Observations showed each resident’s O2 tubing and water bottle remained dated and unchanged beyond the ordered weekly schedule, and the DON confirmed the equipment should have been changed per the orders.
Failure to maintain ordered continuous O2: A resident with stroke and COPD was observed without his NC while a CNA waited for a portable O2 unit to be filled. The CNA then applied the NC but did not turn on the liquid portable O2, and later wheeled the resident to the nurse’s station to have the nurse set the unit to the ordered liter flow. The resident’s physician had ordered continuous O2 2L to 4L NC.
Improper Storage of CPAP Mask and Oxygen Tubing: A resident with COPD, DM, dialysis dependence, and continuous O2 orders had his CPAP/NIV mask observed lying on the bedside table and his O2 tubing wrapped under the concentrator handle instead of being stored in a sanitary container or bag. Staff interviews confirmed the equipment should be stored in a bag when not in use, but it was not being kept that way during observation.
Oxygen equipment not maintained per order
Penalty
Summary
The facility failed to ensure respiratory equipment was properly maintained for one resident who required oxygen therapy. The resident was cognitively intact, had diagnoses including multiple sclerosis and hypoxemia, and the care plan identified shortness of breath related to the diagnoses with oxygen therapy required. The August 2026 TAR directed staff to change oxygen supplies, including the oxygen bubbler and tubing, and to date and initial the change every night shift every Wednesday for routine exchange and maintenance. During observation, the resident was in bed receiving oxygen through a nasal cannula, and the oxygen PM bubbler was dated 6/4/26. RN-A stated the oxygen tubing and bubbler were supposed to be changed weekly and confirmed the bubbler date was overdue, stating it should have been changed. RN-A also stated that if oxygen supplies were not maintained properly, the chance of contracting respiratory infection increased. RN-B, who was also the staff educator, stated nurses were expected to follow provider orders as written, and the DON stated nurses should follow orders as written and that the bubbler should have been changed weekly. Facility policy stated all oxygen equipment should be clean, safe, and functional and all disposable pieces changed weekly.
Bi-pap Therapy Not Ordered or Verified at Admission
Penalty
Summary
The facility failed to ensure respiratory care was provided consistently with professional standards of practice for Resident #56, who had diagnoses including acute respiratory failure with hypercapnia, COPD, cerebral infarction, and dependence on supplemental oxygen. The resident’s prior records sent to the facility before admission documented that he required Bi-pap therapy at night for chronic hypercapnic respiratory failure, with specific settings listed, and that frequent monitoring of respiratory status, oxygen saturation, and adherence to Bi-pap therapy was critical. However, the facility’s baseline care plan did not address supplemental oxygen use or Bi-pap use, and the facility’s order summary showed oxygen at 2 to 4 liters per nasal cannula but no Bi-pap order. The resident told surveyors that he used the Bi-pap machine every night for 5 to 6 hours, but he was unable to use it for three nights because he could not find the connector piece needed to make the machine work. He stated he did not tell facility staff about the missing piece and instead told the hospice RN. During the observation, he was sitting in a wheelchair on oxygen at 3 liters per nasal cannula, with even and unlabored respirations and no shortness of breath. Nursing notes during the stay documented oxygen saturations ranging from 94% to 98% while on oxygen, but the records did not show a Bi-pap order or settings in the hospice orders. Interviews showed that the hospice RN who admitted the resident was not aware he had a Bi-pap machine and did not see it in the facility, and she did not review the DME section of the chart. The admitting LVN and ADON both stated they were unaware of the Bi-pap machine or its missing order/settings, and neither checked whether the equipment was present and working at admission. The DON stated she assumed hospice would write the Bi-pap order and later learned there were no orders for the machine. The Administrator stated the admission nurse was responsible for verifying equipment was in proper working condition and that all needed services and orders were administered. The facility policy on CPAP/Bi-pap described how to use the machine and to contact the DME company if it was not operating correctly, but it did not indicate that orders were required.
Respiratory Care and Tracheostomy Care Not Provided as Ordered
Penalty
Summary
Respiratory care was not provided consistent with professional standards of practice for a resident receiving oxygen. The resident had diagnoses including depression, low blood pressure, and atrial fibrillation, and the MDS indicated oxygen therapy while a resident. During observation, the resident was lying in bed with oxygen on, and the nasal cannula was not dated. The physician order required oxygen at 3 liters per minute via nasal cannula at night or as needed, and another order directed that the oxygen concentrator and filter be cleaned and the tubing changed weekly. During interview, the RN confirmed that the oxygen tubing did not have a date on it and confirmed the facility failed to provide appropriate respiratory care for the resident. Tracheostomy care was also not provided consistent with professional standards of practice for another resident. The resident had diagnoses including diabetes, heart failure, and stroke. Physician orders directed staff to check that the trach mask and oxygen were in place and to assess the need for suctioning, trach care, and oral care four times a day. The care plan directed suctioning of the trach and oral care every shift and every two hours as needed, and to provide oxygen via aerosolized trach mask with tubing and filters changed weekly. During observation, the resident was connected to oxygen via ATM, but heavy thick mucus was visible under the trach, the inside of the trach mask was soiled with mucus, the ATM tubing and nebulizer tubing were not dated, and the tubing was not stored in a bag as required. The suction catheter tubing end was also not stored in a bag as required, and the RN confirmed these findings during interview.
Failure to Change Oxygen Equipment per Physician Orders
Penalty
Summary
The facility failed to maintain respiratory equipment according to physician orders for two residents receiving oxygen therapy. Resident R18 had diagnoses including chronic respiratory failure, COPD, and hypertension, and had an order dated 10/20/25 to change the O2 tubing, water bottle, and tubing bag weekly every Sunday night shift. Resident R20 had diagnoses including COPD, GERD, and hypothyroidism, and also had the same weekly order for oxygen tubing, water bottle, and tubing bag. Facility policy stated medications are to be administered in accordance with written physician orders. On 8/4/26 and again on 8/5/26, observations showed both residents’ oxygen concentrators with water bottles and O2 tubing dated 7/27/26. The dated equipment remained unchanged during the second observation. During interview on 8/5/26, the DON confirmed that both residents’ water bottles and oxygen tubing were dated 7/27/26 and should have been changed per physician orders.
Failure to Maintain Ordered Continuous Oxygen
Penalty
Summary
The facility failed to ensure that Resident #6 received continuous oxygen via nasal cannula as ordered by the physician. The facility’s Oxygen Administration policy dated February 2024 stated staff were to verify a physician’s order and place the appropriate oxygen device on the resident, with oxygen started at the ordered flow rate. Resident #6 was admitted and later readmitted to the facility with diagnoses including stroke and COPD, and the physician’s order dated 6/25/26 specified oxygen 2L to 4L NC continuous. On 8/3/26 at 10:17 AM, Resident #6 was observed sitting in a wheelchair in his room without his oxygen cannula on while CNA #1 stood next to him. CNA #1 stated he was taking Resident #6 out of the room but was waiting for the portable oxygen unit to be filled. When the liquid oxygen unit arrived, CNA #1 attached the tubing and applied the nasal cannula but did not turn on the portable oxygen unit. At 10:26 AM, CNA #1 wheeled Resident #6 to the nurse’s station and waited for the nurse to turn the portable oxygen on to the resident’s liter flow. The resident’s care plan documented oxygen as ordered and to check room air saturation as ordered, wean as able/ordered. On 8/4/26 at 4:40 PM, the RNC stated the CNA should not have taken Resident #6 off oxygen and should have had the nurse set the liquid portable unit to the proper liter flow before placing it on the resident.
Improper Storage of CPAP Mask and Oxygen Tubing
Penalty
Summary
The facility failed to ensure Resident 10’s CPAP/NIV mask and oxygen tubing were stored in a sanitary manner. Resident 10 had diagnoses including DM, COPD, dialysis dependence, and dependence on supplemental oxygen. His record included physician orders for NIV use at night with oxygen at 3 LPM connected to the device, and oxygen at 3 LPM via nasal cannula after the mask was removed in the morning. The resident’s MDS documented a BIMS score of 15, indicating intact cognition, and his care plan included staff assistance with respiratory equipment as ordered. During observation, the resident’s NIV mask was seen lying directly on the bedside table next to the machine rather than in a container. On another observation, the resident’s oxygen tubing was wrapped together and placed under the handle of the oxygen concentrator instead of being stored in a container. A CNA stated she would transfer the oxygen tubing from the concentrator to the portable oxygen tank after getting the resident up and then place the tubing inside the concentrator handle. An LN stated the CPAP mask and oxygen tubing should be stored in a bag when not in use, and an Administrative Nurse stated the respiratory equipment should be cleaned and changed as ordered and stored in the dated bag.
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