F0684

G

Failure to Provide Ordered CPAP Therapy and Timely Physician Notification After Equipment Failure and Change in Condition

Brookfield, Missouri Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide ordered CPAP therapy and to notify the physician in a timely manner when a resident’s CPAP mask broke and when the resident experienced a change in condition. The resident had diagnoses of COPD, chronic respiratory failure, and sleep apnea, and physician orders directed that CPAP with oxygen be applied at bedtime with specific settings. The facility’s own CPAP policy required immediate replacement of broken or malfunctioning equipment. Documentation on the treatment administration record (TAR) beginning on 1/24/26 showed that staff did not apply the resident’s CPAP, and nursing notes on 1/25/26 and 1/26/26 indicated the CPAP mask was missing and no longer in use while awaiting a new mask. Subsequent notes on 1/27/26 and 1/28/26 documented that staff were waiting for replacement pieces and parts to repair the machine, and the TAR continued to show that CPAP was not applied on those dates.

From 1/29/26 through 1/31/26, the TAR consistently showed that staff did not apply the resident’s CPAP. Nursing documentation on 1/30/26 stated the resident was not using CPAP and was awaiting a mask. In the early hours of 1/31/26, nurse notes recorded that the resident had an oxygen saturation of 91% on oxygen via nasal cannula, was lethargic, and was anxious with a recent change in mood, repeatedly asking staff if something was wrong because the resident had slept the day away and did not usually sleep like that. Additional notes that same night described the resident’s continued anxiety, concern about not sleeping normally, the need for a silicone mask that was on order, and oxygen saturation lower than normal. There was no documentation that the nurse contacted the physician regarding the broken CPAP mask or the resident’s change in condition at that time.

The TAR showed that CPAP continued not to be applied on 2/1/26, 2/2/26, and 2/3/26. An email from the facility to an equipment supplier on 2/3/26 indicated the resident immediately needed a new CPAP mask and straps, and the DON requested advice on how to order a new one; the supplier responded that they did not provide CPAP supplies, and the facility then contacted its corporate office to identify the correct supplier. On 2/4/26, nursing notes documented that staff found the resident not verbally responding or behaving as normal, with slightly purple lips and fingers and an oxygen saturation of 75% on 5 liters of oxygen. Despite repositioning and assistance with oxygen intake, the saturation remained around 75%, and the nurse then contacted the physician, who ordered the resident sent to the hospital. Hospital records stated the resident had chronic respiratory failure, normally used 5 liters of oxygen and nightly CPAP, and that per facility report the CPAP had been broken for weeks, with the resident going without CPAP therapy at night for two to three weeks and being sent to the hospital with altered mental status due to hypercapnia likely associated with the CPAP malfunction.

After the resident’s readmission to the facility, physician orders again directed application of CPAP at bedtime with oxygen and specified settings, but the TAR on 2/6/26 still showed staff did not apply the CPAP. The resident’s quarterly MDS later documented that the resident was cognitively intact, had no refusal of care, experienced shortness of breath when lying flat, and used oxygen therapy and noninvasive mechanical ventilation within the last 14 days of the assessment. In interviews, the resident reported having an adverse reaction from the old CPAP that resulted in hospitalization and later receiving a new mask that worked better. The ADON/LPN acknowledged that staff were unable to apply the CPAP because the mask was broken and that the resident went without CPAP for a few days. One LPN stated the mask broke, staff tried to tape it, a piece was lost so it could not be used, and although the LPN observed a change in the resident’s status on 1/31/26 and reported concerns to the DON, the LPN did not call the physician and did not recall notifying the physician about the broken mask or the change in condition. Another LPN knew the mask was broken but did not report it to the physician, citing no observed changes in daily respiratory assessment, and later was unaware that a replacement mask had arrived and did not look for it. The DON and Administrator both stated they expected staff to notify them and the physician when a CPAP mask or ordered equipment was not functioning and when a resident had a change from baseline, but the record showed this did not occur in a timely manner for this resident.