F0695

D

Failure to Obtain and Provide Ordered CPAP Equipment

Overland Park, Kansas Survey Completed on 02-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to obtain and provide a physician‑ordered CPAP machine for a resident with COPD who was admitted with an active CPAP order. The resident’s EMR showed diagnoses including COPD and moderate cognitive impairment, with repeated BIMS scores of eight. The care plan dated 01/15/26 addressed continuous oxygen at 2 L and related interventions such as changing humidification and tubing, educating the resident on oxygen use, and observing oxygen precautions, but did not address the existing CPAP order. The EMR contained orders starting 08/08/25 for CPAP use at bedtime per home settings and for replacing distilled water in the humidifier prior to CPAP/BiPAP use.

Review of the TAR from 08/08/25 to 01/31/26 showed numerous scheduled CPAP administrations documented as given, refused, on hold, or with other notations, despite the resident not having a CPAP machine in the facility. Multiple eMAR notes documented that the resident did not have CPAP equipment, did not use a CPAP, and stated the facility never obtained one. On observation, no CPAP machine was present in the resident’s room, and the resident confirmed she never received one and only used oxygen at night. A nurse acknowledged the resident never had a CPAP in the facility but had an order for it and stated she documented “refused” on the TAR both when the resident declined and when the machine was not available. Administrative nursing staff reported they did not know if the resident had a CPAP, indicated that residents usually brought their own machines, and stated the CPAP order should have been discontinued if no machine was available. The facility’s CPAP/BiPAP policy addressed reviewing physician orders for settings but did not address providing a CPAP machine.