F0656

D

Failure to Care Plan BiPAP Use for Resident With Acute Respiratory Failure

Dallas, Texas Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

Surveyors identified a failure to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes for a resident using a BiPAP device. Record review showed that a male resident with a diagnosis of acute respiratory failure was admitted to the facility and had an intact cognitive status per a Quarterly MDS Assessment. The resident’s physician orders, dated after admission, specified BiPAP settings of 20/8 with 2L O2 at bedtime. However, review of the resident’s Comprehensive Care Plan revealed no care plan addressing the use of the BiPAP device, despite the resident’s respiratory diagnosis and active treatment order.

During interviews, multiple staff members acknowledged that the resident’s BiPAP use should have been included in the care plan. The Unit Manager stated the BiPAP should have been care planned but reported she was not responsible for updating care plans. The ADON stated that the MDS nurse, ADON, DON, and Treatment Nurse updated care plans and confirmed that BiPAP use should be care planned so treatment could be monitored. The MDS nurse acknowledged that since the device was coded on her end, she should have updated the care plan and noted that failure to do so could place the resident in respiratory distress. The DON stated that BiPAP use should be care planned as a special device and explained that if the resident arrived with the device, the MDS nurse should update the care plan, and if new orders were obtained in-house, it was the responsibility of the DON and ADON. The facility’s written policy on Comprehensive Care Plans required inclusion of measurable objectives and timeframes for all services identified in the comprehensive assessment, which was not followed in this case.