F0656

D

Failure to Include BiPAP Use in Comprehensive Care Plans for Two Residents

Dayton, Ohio Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement comprehensive care plans that addressed the use of non-invasive mechanical ventilators (BiPAP) for two residents with chronic respiratory conditions. One resident had diagnoses including COPD, chronic respiratory failure, and obstructive sleep apnea, with an active order for auto BiPAP every night at bedtime and as needed during daytime sleep. A quarterly MDS showed moderately impaired cognitive skills and documented use of a non-invasive mechanical ventilator in the 14-day look-back period. Despite this, the resident’s comprehensive care plan, in place since admission, did not address BiPAP use, even though surveyors observed a BiPAP machine in the resident’s room on multiple occasions. The MDS nurse, responsible for nursing care plans, confirmed during interview that there was no BiPAP care plan and stated the resident should have one so staff would know about the BiPAP.

The second resident had chronic respiratory failure and obstructive sleep apnea, with an order to wear BiPAP at night for sleep apnea and an admission MDS indicating intact cognition and use of a non-invasive mechanical ventilator in the last 14 days of the assessment period. Review of this resident’s comprehensive care plan, initiated at admission, also showed no care plan or interventions related to BiPAP use. The MDS nurse acknowledged the absence of BiPAP-related interventions in this care plan. The DON and the Administrator both stated in interviews that they expected BiPAP use to be addressed on residents’ comprehensive care plans, and the facility’s Comprehensive Care Plans policy required development of person-centered care plans with measurable objectives and timeframes that include all services identified in the comprehensive assessment and meeting professional standards of quality.