F0656

D

Failure to Include CPAP Therapy in Comprehensive Care Plan

Fort Worth, Texas Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan that included CPAP treatment for a resident with obstructive sleep apnea. The resident was an elderly male with diagnoses of Alzheimer’s disease, obstructive sleep apnea, depression, and vertigo, and had a BIMS score of 02 indicating severe cognitive impairment. His quarterly MDS showed he required partial to moderate assistance with bed mobility and transfers, supervision for walking, and used a walker or wheelchair, with a history of falls. Despite medical orders dated 08/07/2025 for daily CPAP equipment cleaning and an order dated 02/10/2026 specifying CPAP use at night with a setting of 8.0 cm H2O for obstructive sleep apnea, the comprehensive care plan dated 02/03/2026 did not address his CPAP treatment.

Surveyor interviews and record reviews showed that multiple staff members acknowledged the resident received nightly CPAP treatments but were unaware that this treatment was not reflected in the care plan. The MDS coordinator stated she relies on the TAR during the 7‑day look‑back period to code the MDS and would not address a treatment if it was left off the TAR. Nursing staff, including LVNs and an RN, confirmed the resident’s CPAP use and, upon review, recognized that omission from the care plan could result in missed care and treatment. The DON and Administrator both stated their expectation that care plans reflect current treatments, including CPAP, and the facility’s written policy required an interdisciplinary, resident-centered comprehensive care plan that identifies care needs, measurable goals, and approaches, to be developed and revised based on assessments. Despite these expectations and policies, the resident’s CPAP treatment was not incorporated into the care plan.