Failure to Provide and Maintain CPAP Therapy for Two Residents
Penalty
Summary
The facility failed to provide necessary respiratory care and services for two residents requiring CPAP therapy. For one resident with a physician's order for nightly CPAP use due to sleep apnea, the CPAP mask was observed on the floor, and there was no designated bag available in the room for sanitary storage. During an interview, an LVN confirmed the absence of a storage bag and acknowledged the infection risk associated with the mask being on the floor. The Director of Nursing also verified that the mask should not have been on the floor. For another resident, also with a physician's order and care plan for nightly CPAP use to treat obstructive sleep apnea, there was no CPAP machine present in the room. The resident reported not having received a CPAP machine since admission. Both an RN and the Director of Nursing confirmed the absence of the CPAP machine and that the resident was not receiving the prescribed treatment. These findings were acknowledged by facility leadership.
Plan Of Correction
Residents Affected: On 9/19/2025, all residents on CPAP were observed by the RN Supervisor to verify compliance. No other residents were affected. Corrective Action: Licensed staff were inservice re-educated on respiratory care procedures by the DON on 09/19/2025 on the facility policy and procedure, for oxygen administration/CPAP. Monitoring of Corrective Action: The DON or their designee will perform daily room rounds to verify compliance with the CPAP administration policy and procedure. Identify deficient practices will be corrected by the DON or designee. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed. Completion Date: 10/25/2025 --- F0698-Dialysis Care and Services Immediate Corrective Action: Resident #10, #18-DON began inservicing licensed nurses on proper documentation pre and post dialysis, correct access site on 09/23/25, and ensuring that resident receive dialysis treatment from outpatient center 09/23/25. Resident #10-DON began inservicing licensed nurses on proper documentation of the dialysis site 09/23/25. Residents Affected: All dialysis residents were assessed and their communication forms were completely filled out with accurate site and information on 09/23/25. No other residents were affected. Corrective Action: Nursing staff were re-educated / in-service by the DON on 09/23/2025 on policy and procedure for dialysis care, ensuring that the resident receive dialysis treatment from outpatient center and proper documentation of the dialysis site. Monitoring of Corrective Action: The DON or their designee will perform weekly audits on dialysis residents to ensure policy and procedure on dialysis care is followed and proper documentation for the access sites, monitoring to ensure that resident receive dialysis treatment from outpatient center.