Failure to Accurately Code CPAP Treatment on MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s Minimum Data Set (MDS) assessment accurately reflected ordered CPAP treatment. A quarterly MDS for Resident #1 did not code the use of a non-invasive mechanical ventilator/CPAP in Section O (Special Treatments, Procedures and Programs), despite medical record documentation and staff interviews confirming ongoing CPAP use. The resident, an elderly male with diagnoses including Alzheimer’s disease with severe cognitive impairment (BIMS score of 02), obstructive sleep apnea, depression, and vertigo, had physician orders dated 08/07/2025 for daily CPAP-related care, including wiping the mask and nasal pillows, emptying the humidifier chamber, cleaning it with warm soapy water, rinsing, and air drying. The care plan dated 02/03/2026 addressed cognitive impairment, impaired thought processes related to Alzheimer’s, risk for falls, and communication problems, but the MDS did not reflect the CPAP treatment in Section O. During observations, the resident’s CPAP mask was seen on the nightstand while the resident was in the memory care common area attending activities, and the resident could not be interviewed due to severe cognitive impairment. Multiple staff interviews, including with the FM, RN, LVN, and DON, confirmed that the resident received CPAP treatment every night at bedtime since admission. The MDS coordinator stated that Section O would not be coded if the resident had not used the CPAP during the 7-day look-back period and acknowledged that failing to code the treatment could place the resident at risk of missing physician-ordered treatments. The Administrator stated it was her expectation that staff code treatments accurately on assessments and that she was not aware of the risk to residents if treatment was not coded. The surveyor repeatedly requested the facility’s MDS assessment policies from the DON and Administrator on multiple occasions, but no policy was provided prior to survey exit.
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