Failure to Implement and Document Ordered BiPAP/CPAP Therapy
Penalty
Summary
The facility failed to ensure that a resident’s BiPAP/CPAP therapy was implemented and documented according to physician recommendations and the resident’s care plan. The resident, who had diagnoses including congestive heart failure, obstructive sleep apnea, bronchiectasis, and chronic respiratory failure, was care planned on 05/18/22 as being at risk for altered respiratory status, with an intervention to assist in ensuring the BiPAP/CPAP mask was in place nightly per order. The quarterly MDS showed the resident had intact cognition and was receiving non-invasive oxygen therapy. However, review of physician orders from 08/11/22 through discharge on 10/14/25 revealed no physician order for BiPAP/CPAP therapy, aside from an order dated 05/04/24 directing staff to cleanse the BiPAP mask weekly on Sundays. Review of the resident’s medical record, including TARs, task worksheets, and nursing progress notes, showed no evidence that BiPAP/CPAP therapy was administered nightly as indicated in the care plan. The resident’s family representative reported that there had been an order for CPAP upon admission and stated the facility did not ensure the resident was using the CPAP machine as ordered, and that she was not informed when the resident refused the therapy. In an interview, the Administrator and DON confirmed that the medical record lacked documentation of BiPAP/CPAP administration and acknowledged there were no physician orders to administer it nightly, although there should have been. This deficiency was cited under Complaint Number 2705837.
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