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F0658
D

Lack of Physician Orders and Standardized Procedures for CPAP Devices

Gettysburg, South Dakota Survey Completed on 07-31-2025

Penalty

Fine: $12,735
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to obtain physician orders for the use of CPAP devices for two residents, as evidenced by record review and staff interviews. Both residents' care plans indicated the use of CPAP devices, but there were no corresponding medical orders documented in their electronic medical records. Staff interviews revealed a lack of clarity and consistency regarding training and procedures for CPAP use and cleaning. The DON confirmed that there was no current policy for obtaining physician orders for CPAP devices, and CPAP was not included on any of the checklists used by nurses for new orders, admissions, or returns from the hospital. Additionally, the facility did not have a formal policy or standardized process for cleaning CPAP devices. Staff members, including CNAs and a CMA, reported being trained on CPAP cleaning either by other staff or by a resident's family, but could not recall specific details about the training or its frequency. The DON stated that the facility relied on manufacturer guidelines for equipment but did not have a written policy for CPAP cleaning or physician orders. The lack of a structured process and documentation led to inconsistent practices and the absence of required physician orders for residents using CPAP devices.

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