F0695

D

Lack of Physician Order and Care Plan Integration for CPAP Use

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

Penalty

No penalty information released

Summary

The facility failed to ensure that a resident who required respiratory care received such care in accordance with professional standards and a comprehensive person-centered care plan. A male resident with diagnoses including Alzheimer's disease, obstructive sleep apnea, depression, and vertigo, and with a severely impaired BIMS score of 02, was using a CPAP machine at night for obstructive sleep apnea. The quarterly MDS did not reflect any special treatments or programs for non-invasive mechanical ventilation and did not address the resident's use of a CPAP machine. The resident's care plan, dated 02/03/2026, addressed cognitive impairment, risk for falls, dependence on staff for needs, and communication problems, but did not address CPAP treatments per medical orders.

Record review showed that existing physician orders dated 08/07/2025 only addressed cleaning and maintenance of the CPAP equipment, including wiping masks and nasal pillows daily, emptying humidifier chambers, filling with warm soapy water, shaking, rinsing, and air drying. There was no physician order in place at that time for the actual use of the CPAP machine, including settings or administration as a respiratory treatment. During observations and interviews, nursing staff, including an LVN and an RN, confirmed that the resident received CPAP treatments nightly for obstructive sleep apnea and reported no concerns with its daily administration, but review of the electronic medical record revealed only cleaning orders. The ADON stated that nursing staff were responsible for ensuring MD orders were entered into the EMR and was not aware that there was no order for CPAP treatments, acknowledging that failing to have an MD order could place the resident at risk of not receiving treatment.