F0695

D

Failure to Protect BiPAP Equipment and Obtain Complete BiPAP Orders

Mattoon, Illinois Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The facility failed to provide safe and appropriate respiratory care by not protecting one resident’s BiPAP mask from potential cross-contamination and by not obtaining complete physician orders for BiPAP settings for two other residents. One resident with acute and chronic respiratory failure with hypercapnia, chronic CHF, morbid obesity with alveolar hypoventilation, insomnia, and obstructive sleep apnea had a physician order to use a BiPAP ventilator while sleeping with specified inspiratory and expiratory pressures. During observation, this resident’s BiPAP mouth mask was found sitting in direct contact with a small table surface at the foot of the bed without any protective covering, despite the resident stating she required staff assistance to place and remove the mask. The DON confirmed the mask was not in a protective covering and acknowledged the facility practice was to place BiPAP masks in a plastic bag.

The facility also failed to obtain complete physician orders for BiPAP pressure settings for two additional residents with significant respiratory and cardiac diagnoses. One resident with chronic bronchitis, asthma, morbid obesity, obstructive sleep apnea, and chronic CHF had a physician order to wear a BiPAP while sleeping, but the order did not include inspiratory or expiratory pressure settings. Another resident with COPD, acute respiratory failure with hypoxia, acute and chronic CHF, morbid obesity, obstructive sleep apnea, pulmonary hypertension, tachypnea, and insomnia had a physician order to wear BiPAP as tolerated and to maintain IPAP, but no specific pressure setting was listed. These omissions occurred despite the facility’s CPAP/BiPAP Support policy requiring nursing staff to review physician orders for prescribed oxygen concentration, flow, and pressure settings, including CPAP, IPAP, and EPAP.