F0695

E

Failure to Follow CPAP/BiPAP Orders and Perform Required Daily Equipment Cleaning

Chicago, Illinois Survey Completed on 03-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow physician orders for BiPAP/CPAP use and to ensure daily cleaning of BiPAP/CPAP equipment for multiple residents with sleep apnea and complex respiratory conditions. One resident with acute and chronic respiratory failure, morbid obesity (BMI ≥70), obstructive sleep apnea, and chronic heart failure was admitted with an order for BiPAP via full mask at bedtime. The admission summary and physician documentation confirmed that this resident was to receive BiPAP nightly. The resident reported that on the first night after admission he did not receive BiPAP, only oxygen via nasal cannula, and that he subsequently "passed out" and was transferred to the hospital the following morning. The clinical record for that night did not show documentation that BiPAP was applied at bedtime as ordered. Nursing staff interviews were inconsistent: the admitting RN stated BiPAP should have been documented on the MAR/TAR if given, and the night RN later stated she did not place the BiPAP mask until after 1:00 a.m., removed it around 4:00 a.m., then briefly reapplied it around 5:00 a.m., with no corresponding documentation in the record.

On the morning after admission, staff observed this same resident to be very sleepy and difficult to keep awake, with increased respiratory rate. The CNA reported that the resident was on oxygen, looking at him but not speaking, and not eating breakfast, prompting notification of the nurse. The day RN confirmed that at shift change the resident was sleeping in bed with oxygen via nasal cannula and that the BiPAP machine was not on. The nurse practitioner evaluated the resident twice that morning, noting that he was not waking up, had tachypnea with respiratory rates in the high 20s to low 30s, and required increased oxygen, leading to transfer to the hospital for altered mental status and acute respiratory failure. The NP and physician both stated that failure to provide BiPAP at bedtime as ordered could potentially contribute to a change in mental status, although they also cited the resident’s chronic respiratory failure, morbid obesity, obstructive sleep apnea, and other comorbidities as contributing factors. The facility’s own policy required that CPAP/BiPAP be ordered by a physician, set up by respiratory therapy, and that mask, tubing, and exhalation port be cleaned daily.

For four additional residents with intact cognition and diagnoses including obstructive sleep apnea, chronic respiratory failure, COPD, morbid obesity, and other serious conditions, surveyors observed CPAP or BiPAP machines at bedside and confirmed active physician orders for nightly use. These residents reported using their devices at bedtime, sometimes inconsistently due to discomfort or personal preference, and one resident stated that staff had not cleaned the CPAP device for months, only wiping off excess water from the mask. For all five residents reviewed (including the first resident), the February and March MARs, TARs, and progress notes did not reflect that CPAP/BiPAP masks, tubing, and exhalation ports were cleaned daily as required by facility policy. The DON confirmed that nurses were expected to follow physician orders for CPAP/BiPAP, document administration on the MAR/TAR or in progress notes, and clean the devices daily for infection control, stating that if it was not documented, it was considered not done. This combination of missing documentation of ordered BiPAP use and lack of documented daily cleaning of CPAP/BiPAP equipment constituted the identified deficiency.