F0695

D

CPAP and Oxygen Administered Without Physician Orders

Dayton, Ohio Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to obtain physician orders prior to administering CPAP therapy and supplemental oxygen to a resident. The resident was admitted with diagnoses including a stress fracture of the left femur, COPD, type 2 diabetes mellitus with complications, and morbid obesity. The care plan, initiated shortly after admission, identified altered cardiovascular and respiratory status related to hypertension, iron deficiency anemia, sleep apnea, and COPD, and included interventions to provide oxygen as ordered by a physician. The admission MDS documented that the resident was cognitively intact, required varying levels of assistance with ADLs, and used oxygen therapy. However, review of the physician orders revealed no orders for CPAP use or for oxygen administration. Despite this, clinical notes documented the resident on oxygen via mask, CPAP, and nasal cannula on multiple dates, with recorded oxygen saturations ranging from 90% to 96%.

Surveyor observations showed a CPAP machine, oxygen concentrator, and portable oxygen tank present in the resident’s room, and on multiple mornings the resident was observed in bed with a CPAP mask in place, oxygen at 2 liters attached through CPAP tubing, and the CPAP set at 6 cmH2O. In interviews, the resident reported using the CPAP with 2 liters of oxygen every night since admission, and an LPN confirmed nightly use of CPAP and oxygen and acknowledged there were no physician orders for the CPAP setting or oxygen flow rate. The DON also confirmed that the resident had oxygen in the room and had not had physician orders for oxygen or CPAP use since admission. The facility’s oxygen policy stated that oxygen would be used in a safe manner, but the documented and observed use of CPAP and oxygen occurred without corresponding physician orders.