Failure to Ensure Safe Use of CPAP Machine
Summary
The facility failed to provide safe and appropriate respiratory care for a resident using a home CPAP machine. The resident, who was admitted with diagnoses including COPD, asthma, and obstructive sleep apnea, did not have a physician's order for the use of the CPAP machine in the facility. Additionally, there was no assessment of the CPAP machine's integrity, no monitoring of the resident's respiratory condition or response to therapy, and no care plan that included interventions for CPAP therapy. Observations and interviews revealed that the resident's CPAP machine and mask had not been checked or cleaned according to the manufacturer's guidelines, which included daily cleaning of the mask and tubing. The resident confirmed that the mask and tubing had not been changed for several weeks. The facility's staff, including a registered nurse and a respiratory therapist, acknowledged the lack of a physician's order, assessment, and care plan for the CPAP machine, as well as the failure to clean the equipment as required. The Director of Nursing and the Infection Preventionist also confirmed these deficiencies, emphasizing the importance of having a physician's order, a care plan, and proper cleaning procedures to prevent respiratory infections. The facility's policies and procedures, as well as the CPAP machine's user manual, outlined the necessary steps for safe and effective use of the CPAP machine, which were not followed in this case.
Plan Of Correction
A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Resident 29's physician assessed the use of the CPAP machine and provided orders for its use and monitoring. The licensed nurse transcribed the physician order for the use and monitoring of Resident 29's CPAP machine on 2/26/2025. The Director of Maintenance evaluated the CPAP machine's safety and integrity on 2/26/2025. The licensed staff are monitoring Resident 29's use of CPAP machine daily and documenting the monitoring in the treatment administration record. The CPAP machine is cleaned routinely per manufacturer's guidelines by the Licensed Vocational Nurses. The IDT developed and initiated a care plan for the use of Resident 29's CPAP including interventions for assessment and monitoring of Resident 29's respiratory status and care of the CPAP machine on 2/26/2025. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken; Residents using home CPAP machines are potentially affected by the facility practice. The Assistant Director of Nursing audited all residents who use CPAP machines. A total of 3 residents use CPAP machines. 0 of 3 residents CPAP machines were brought from home. No other residents identified affected by the facility practice. The IDT audited care plans of residents who use a CPAP machine for respiratory conditions to ensure interventions including an assessment, physician order, monitoring and cleaning were present on 2/26/2025. C. What measures will be put into place or what systematic changes the facility make to ensure that the deficient practice does not recur; The Director of Nursing/designee will re-educate the nursing staff on or before 3/21/2025, re: the facility policy and procedures, Care Planning, with emphasis on residents with CPAP therapy must have person-centered interventions based on the assessment including evaluation of the safety and integrity of a CPAP machine, when brought from home, No Smoking sign at the resident's door, tubing and mask materials, routine evaluation of respiratory condition through pulse oximeter and routine cleaning per manufacturers guidelines for the CPAP machine. The Interdisciplinary Team will evaluate newly admitted residents for to identify residents with CPAP therapy to ensure the completion of an assessment, physician order and comprehensive person-centered care plan with interventions for CPAP therapy, routine cleaning of the mask and replacement of the tubing, and cleaning of the CPAP machine. Charge nurses will complete routine pulse oximetry each shift of residents with CPAP machines. D. How the facility plans to monitor its performance to make sure solutions are sustained; The Infection Prevention Nurse/designee will monitor residents who use CPAP therapy to ensure cleanliness of the mask, tubing and machine per manufacturer's guidelines to reduce the risk of residents developing respiratory infection. The Charge Nurse will monitor the residents' respiratory health, assess the resident's pulse oximetry and document in the medication administration record each shift. Concerns identified will be corrected at the time of observation and reported to the Director of Nursing. The Director of Nursing will monitor the licensed nurses' performance through observation and IPN reports; and provide re-education or progressive disciplinary action as indicated. The DON/designee will report trends identified in CPAP therapy to the Quality Assurance committee during the quarterly QA&A meeting for the purpose of process improvement changes to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025 --- F697 Pain Management CFR(s): 483.25(k) A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; The licensed nurse completed a pain assessment of Resident 65 to ensure current pain management program is effective on 2/24/2025. CNA 1 received 1:1 re-education on the facility procedure to report resident complaints of pain to the charge nurse for further evaluation on 2/24/2025. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken; Residents cared for by certified nurse assistant 1 are potentially affected. The Charge Nurse interviewed residents cared for by CNA 1 on 2/24/2025 and completed a pain assessment in the medication administration record to identify residents who had unreported complaints of pain. No other residents had complaints of pain that were not conveyed to the charge nurse. No other residents were affected by the facility practice.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Surveyors observed four full O2 cylinders on one nursing unit stored unsecured directly on the floor under a sign labeled "FULL CYLINDERS" instead of in a secured storage rack. The ADON confirmed the cylinders were full and should not be on the ground. Reference to NFPA 99 showed that freestanding cylinders must be protected from damage and properly chained or supported in a stand or cart. The DON and Maintenance Director both acknowledged that O2 cylinders are required to be stored in a secure rack, should never be on the floor, and that unsecured cylinders on the floor present a safety risk.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
A resident with COPD and dementia, receiving scheduled nebulizer treatments, was found on multiple occasions to have a nebulizer mask stored on top of the machine rather than in a sanitary manner. A CNA and a nurse aide in training confirmed the mask’s placement, and an LPN reported that masks were routinely cleaned, dried, and then stored on top of the machine. The DON later acknowledged that masks should be washed, dried, and placed on a clean surface, and facility policy required oxygen and respiratory supplies to be stored in a plastic bag when not in use.
A resident was observed receiving O2 via nasal cannula on multiple occasions, but the chart had no current physician order for O2. The resident said she had been told after a recent hospitalization to use O2 for 30 days, but that time had passed and she was still using it because staff told her she needed it. The DON confirmed there was no current O2 order; the last order had already been discontinued.
A resident with acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes was observed receiving oxygen at 4.5 L/min via nasal cannula without a corresponding physician order in the clinical record. The DON acknowledged that an order should have been in place before oxygen was initiated. Facility policy on supplemental oxygen via nasal cannula requires administration only under a physician or provider order, in alignment with 410 IAC 16.2-3.1-47(a)(6).
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Unsecured Storage of Full Oxygen Cylinders on Nursing Unit
Penalty
Summary
Surveyors found that the facility failed to ensure safe storage of oxygen cylinders on the West 1 unit. At 9:03 a.m., four full oxygen cylinders were observed stored unsecured directly on the ground rather than in the designated secured cylinder storage rack, under a sign labeled "FULL CYLINDERS." Photographic evidence was obtained of this condition. At 9:18 a.m., the ADON confirmed that the four cylinders were full and acknowledged they should not be stored on the ground. Review of NFPA 99 (2021) 11.6.2.3(11) indicated that cylinders must be protected from damage and that freestanding cylinders must be properly chained or supported in a proper stand or cart. Later that day, the DON stated that oxygen cylinders should be stored in a secure rack and never directly on the ground, and acknowledged that unsecured cylinders on the floor were a safety risk. The Maintenance Director also confirmed that oxygen cylinders should be in a secure rack and never stored directly on the ground, stating that cylinders stored on the floor can tip over and cause damage. These observations and interviews demonstrated noncompliance with regulatory and NFPA standards for safe storage of oxygen cylinders.
Plan Of Correction
This plan of correction constitutes a written allegation of compliance for the deficiency cited. Submission of this plan of correction is not an admission that the deficiency exists or that one was cited correctly. This plan of correction is submitted to meet the requirements established by the State and Federal law. The four unsecured [R] cylinders on the West 1 unit were secured. The Nursing Department completed a baseline audit of [R] cylinder storage within the facility to ensure all [R] cylinders were secured and stored properly. Ongoing education will be completed with current facility staff regarding the facility's [R] storage policy and procedure; and will be completed during new hire and agency orientation to the facility by ADON/designee. Audits will be completed by the Director of Nursing/designee regarding adherence to the facility's [R] storage policy and procedure twice weekly x 4 weeks, then weekly x 4 weeks, then monthly x 4 months, or until continued substantial compliance has been met. Results of audits will be reported to the QAPI Committee on a monthly basis by the Director of Nursing/designee.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Improper Storage of Nebulizer Mask and Respiratory Supplies
Penalty
Summary
Surveyors identified a deficiency in the sanitary storage of respiratory equipment for one resident receiving respiratory care. The resident was admitted with COPD and unspecified dementia and had care plan focuses for terminal prognosis due to COPD and shortness of breath, with interventions including administration of inhalers and nebulized medications as ordered. Physician orders included scheduled ipratropium-albuterol nebulizer treatments twice daily for COPD. During multiple observations in the resident’s shared room, the nebulizer mask was seen lying on top of the nebulizer machine rather than being stored in a sanitary manner. Staff interviews confirmed the observed storage practice. A CNA and a nurse aide in training each verified that the nebulizer mask was lying on top of the machine at the times of observation. An LPN stated that masks were cleaned after use, dried, and then stored on top of the machine, and acknowledged this could be an infection control issue. During a later observation, the LPN again confirmed the mask was on top of the machine. In an interview, the DON, with the Administrator present, stated the mask should be washed, dried, and placed on a clean surface and acknowledged it could be an infection control issue, and the facility’s written policy specified that oxygen and respiratory supplies were to be stored in a plastic bag when not in use.
Missing Current Physician Order for Oxygen
Penalty
Summary
The facility failed to ensure a current physician's order was in place for a resident receiving oxygen via nasal cannula. Resident 3 was observed in her room on multiple occasions using oxygen from a humidifying oxygen delivery machine via nasal cannula. During interview, the resident stated she had been told after her last hospitalization to use oxygen for another 30 days, but that time had passed and she was still wearing the nasal cannula and receiving oxygen because staff told her she needed it; she also stated the nasal cannula bothered her and she did not want to wear it if it was not necessary. Review of the clinical record showed diagnoses including atrial fibrillation and anxiety, but no current oxygen order. The last oxygen order had a start date of 2/2/26 and a discontinued date of 2/23/26. The DON confirmed there was no current physician's order for oxygen for the resident.
Oxygen Administered Without Required Physician Order
Penalty
Summary
The facility failed to ensure physician orders were in place for oxygen administration for one resident receiving respiratory care. During an observation on 5/8/26 at 9:45 a.m., Resident 101 was noted to be receiving oxygen at 4.5 liters per minute via nasal cannula. Review of the resident’s clinical record later that day showed diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes, but no physician’s order for the use of oxygen could be located at the time of review. In a subsequent interview on 5/12/26 at 8:14 a.m., the Director of Nursing stated that physician orders for oxygen should have been present in the record before oxygen was initiated. The facility’s undated policy titled “Supplemental Oxygen Using Nasal Cannula,” provided on 5/13/26, specified that supplemental oxygen may be administered via nasal cannula only at the order of a physician or provider, consistent with 410 IAC 16.2-3.1-47(a)(6). These observations, interviews, and record reviews demonstrate that oxygen was administered to Resident 101 without the required physician order, contrary to both facility policy and state regulatory requirements.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
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