F0656

E

Failure to Integrate Respiratory Treatments and Equipment Care Into Comprehensive Care Plans

Fort Worth, Texas Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and time frames for residents receiving respiratory treatments and equipment. For three residents reviewed, the care plans did not fully address their respiratory therapy needs as reflected in physician orders and actual use of equipment. The facility’s own policy required timely, person-centered comprehensive care plans that are reviewed and revised by an interdisciplinary team when resident conditions or treatments change.

For one resident with obstructive sleep apnea and a BIMS score indicating moderate cognitive impairment, the MDS documented respiratory therapy and active diagnoses including obstructive sleep apnea. The care plan noted altered respiratory status related to sleep apnea and included a goal that the resident would have no signs or symptoms of poor oxygen absorption, with an intervention to assist with putting on and taking off the BIPAP mask at bedtime and in the morning. However, the care plan did not address BIPAP use, storage, or cleaning, despite MD orders specifying BIPAP settings, use while sleeping or napping, and detailed cleaning instructions for the mask and reservoir. During observation, the resident’s BIPAP mask and hose were seen on the nightstand with a small greasy and cloudy film from daily facial use, and the resident stated staff had removed the mask that morning.

For a second resident with COPD, multiple fractures, and a BIMS score indicating moderate cognitive impairment, the MDS and MD orders documented continuous oxygen via nasal cannula and specific orders to change oxygen tubing, nebulizer circuit, and humidifier bottle on a set schedule, with labeling when changed and as needed when soiled. The admission care plan addressed COPD with respiratory failure, included a goal for optimal breathing patterns, and listed interventions such as elevating the head of bed and monitoring for signs and symptoms of respiratory infection and acute respiratory insufficiency, as well as documenting oxygen settings. The care plan did not address the frequency of oxygen tubing changes or labeling, even though MD orders required these tasks. During observation, the resident was seen in bed wearing an undated nasal cannula and denied concerns with the oxygen machines.

For a third resident with intact cognition, obstructive sleep apnea, and asthma, the MDS documented use of a wheelchair and walker and dependence on staff for several ADLs. The care plan addressed hypertension, including administration of antihypertensive medications, monitoring for side effects, and obtaining blood pressure readings prior to medication administration. Section O of the MDS reflected special treatments and procedures, and MD orders included monitoring for shortness of breath when lying flat, PRN nebulized albuterol for shortness of breath and wheezing, and an order for BIPAP with specified settings to be applied upon availability. The resident’s care plan did not address BIPAP use, storage, or cleaning. In interviews, the DON stated clinical staff were responsible for updating care plans and that the EMR provided prompts, and acknowledged that residents were receiving respiratory treatments per MD orders but did not explain why these treatments were not reflected in the care plans. The Administrator stated the DON was responsible for monitoring and ensuring resident care tasks were addressed and accurate, and that care plans address residents’ individual medical needs and treatments, but did not provide additional information regarding the non-compliance with care plans.

The facility’s written policy on comprehensive care plans and revision, dated and reviewed as noted in the record, stated that the facility would ensure timeliness of each resident’s person-centered comprehensive care plan and that the plan would be reviewed and revised by an interdisciplinary team knowledgeable about the resident and their needs, with resident and representative involvement. The policy further stated that the facility should monitor residents over time to identify changes that may warrant updates to the care plan, and when such changes occur, the care plan should be reviewed and updated to reflect changes in care delivery, including adding interventions, updating goals or problem statements, or adding short-term problems, goals, and interventions. Despite this policy, the care plans for the three residents did not incorporate the specific respiratory treatments, equipment care, and related tasks ordered by physicians and documented in the medical record.