§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
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Observations:
Based on interview with resident and staff, review of facility policy and documentation as well as review of clinical record, it was determined that facility failed to provide respiratory care to one resident according to professional standards of practice. The facility's failure to consistently administer and document life-sustaining AVAPS therapy and physician-ordered oxygen parameters resulted in actual physical harm and significant clinical decline for Resident R3. (Resident R3)
Findings include:
Review of undated facility policy 'Respiratory Therapy Services in Long-Term Care,' revealed thepurpose is to "ensure safe, effective, and compliant respiratory therapy services for residents requiring respiratory care in the long-term care setting."
Further review of same facility policy revealed staff are responsible for working collaboratively with physicians, nursing staff, rehabilitative services, and other interdisciplinary team members and document assessments/treatments, resident response, and education in the medical record.
Review of Resident R3 clinical record revealed medical history of Toxic Encephalopathy (type of brain dysfunction caused by exposure to toxic substances that damage or disrupt brain function. It affects how the brain works, leading to problems with thinking, memory, behavior, or movement), Chronic Obstructive Pulmonary Disease (COPD - ongoing lung condition caused by damage to the lungs. The damage results in swelling and irritation, also called inflammation, inside the airways that limit airflow into and out of the lungs) with exacerbation, Acute and Chronic Respiratory Failure with Hypoxia (low oxygen level) and Hypercapnia (too much carbon dioxide (CO2) in the blood), Pneumonia (infection that inflames the air sacs of one or both lungs), Dementia (describes a group of symptoms affecting memory, thinking and social abilities, which interfere with a person's daily life).
Review of Resident R3's minimum data set assessment (MDS - periodic assessment of resident abilities and care needs) completed February 20, 2026, revealed a Brief Interview for Mental Status (BIMS) score of 14 (indicating functioning cognitive ability).
Review of Resident R3's clinical record revealed the resident was hospitalized on February 15, 2026, due to "COPD exacerbation" and was re-admitted to facility on February 18, 2026, status post for "acute on chronic respiratory failure with hypoxia and hypercapnia leading of noncompliance with AVAPS (machine is a smart ventilator that automatically adjusts air pressure to ensure the lungs receive a consistent volume of air, specifically designed to 'blow off' excess CO-2 (carbon dioxide)."
Review of Resident R3's physician orders revealed an order placed on February 18, 2026, to "clean CPAP/BIPAP/AVAPS (types of non-invasive positive pressure ventilation (NIPPV) used to support breathing, usually delivered through a mask rather than a breathing tube. They are commonly used for conditions like Obstructive Sleep Apnea, Chronic Obstructive Pulmonary Disease, and Acute Respiratory Failure)Reservoir in the morning."
Review of Resident R3's physician orders revealed that on February 17, 2026, (11:00 PM), an order was issued to assist resident with application of the Trilogy V60 ventilator at bedtime (QHS). The ordered settings included: EPAP 5 cm H2O, AutoPAP minimum pressure 16 cm H2O, AutoPAP maximum pressure 25 cm H2O, target tidal volume 365 mL, minimum EPAP 4.0 cm H2O, set respiratory rate 8 breaths per minute, and FiO2 45%. The order also instructed staff to document any refusal of AVAPS therapy during each evening and night shift. The intervention was ordered for management of Chronic Obstructive Pulmonary Disease with exacerbation and could be used as needed (PRN) for COPD symptoms.
Further review of physician orders revealed an order placed on February 17, 2026, for "oxygen at 3 liters/min via nasal cannula continuously maintain SpO2 88% - 92% every shift." (typical SpO2 target for COPD residents is 88 92% while using AVAPS to avoid worsening Hypercapnia (condition where too much carbon dioxide (CO2) builds up in the bloodstream from excessive oxygen).
Review of Resident R3's care plan revealed a focus of "Trilogy settings as follows: VT 400ml, Rate 3.0 cmh2o, Pressure support min 8.0 cmh2o, Pressure support max 15.0 cmh2o, Epap min 4.0 cmh2o, Epap max 6.0 cmh2o, Avaps rate 3.0cm, Max pressure 21.0 cmh2o" and interventions "monitor/document changes in orientation, increased restlessness, anxiety, and air hunger and to monitor for signs and symptoms of respiratory distress and report to medical director as needed: Increased Respirations; Decreased Pulse oximetry; Increased heart rate (Tachycardia); Restlessness; Diaphoresis; Headaches; Lethargy; Confusion; Hemoptysis; Cough; Pleuritic pain; Accessory muscle usage; Skin color changes to blue/grey" initiated on January 19, 2024 with revision on March 22, 2024.
Further review of care plan revealed Resident R3 has altered respiratory status/difficulty breathing related to COPD with exacerbation and oxygen therapy related to COPD with interventions to Assist with head of the bed to 45-degrees, Change residents position every 2 hours to facilitate lung secretion movement and drainage, Monitor resident for shortness of breath while lying flat, and O2 via nasal as ordered every shift, revised January 16, 2025.
Interview conducted with Resident R3 on March 3, 2026, at 12:00 pm, revealed that he/she is unable to differentiate between CPAP/BIPAP/AVAPS machines.
Review of electronic treatment administration record (e-TAR) for month of February 2026, revealed oxygen levels (SpO2) have been maintained between 94% - 99%, contradictory to the physician ordered of February 17, 2026, for "oxygen at 3 liters/min via nasal cannula continuously maintain SpO2 88% - 92% every shift." (typical SpO-2 target for individuals diagnosed with COPD is 88 92% while using AVAPS to avoid worsening Hypercapnia from excessive oxygen).
Further review of e-TAR (electronic treatment administration record between February 17, 2026, and February 25, 2026, revealed of 15 required evening/nightly shift AVAPS applications, 8 shifts (53%) contained missing or unclear documentation of treatment or refusal.
Further review of e-TAR revealed missing documentation related to cleaning Resident R3's respiratory appliances on the following dates: day shifts on February 21, 2026, and February 23, 2026.
Review ofResident R3's clinical record including nursing note, dated February 24, 2026, (6:00 pm), revealed AVAPS was applied due to "pulse ox (non-invasive device that measures how much oxygen is in the blood) dropping to 60%," and Resident R3 was noted to have confusion. Further review of progress notes revealed Resident R3 refused AVAPS application "last night"/overnight shift from February 23, 2026, 11:00 pm through February 24, 2026, 7:00 am.
Review of Resident R3's e-TAR documentation of same time frame revealed AVAPS was applied.
Further review of e-TAR revealed "N/A" and "0" documented under AVAPS application on February 18, 2026 night shift, February 20, 2026 evening shift, February 22, 2026 evening shift, February 23, 2026 evening shift.
Interview conductedon March 4th, 2026 at 2:00 p.m. with the facility's director of nursing was unable to provide clarification on what "0" and "NA" notation on Resident R3's February 2026e-TAR indicates.
Review of Resident R3's care plan revealed "refusal of avaps at times," initiated and revised on March 4, 2026, with no follow-up interventions related to refusing AVAPS.
Further review of the clinical record failed to reveal evidence the AVAPS treatment refusals were communicated to physician.
Further review of Resident R3's clinical record revealed Resident R3 was transferred to emergency room again on morning of February 25, 2026, per family member's request and was seen for shortness of breath and carbon dioxide at the upper end of the normal range (45). The resident's presentation of shortness of breath; with, CO-2 levels were measured at 45 mmHg.
Further review of clinical record revealed Resident R3 was re-admitted to facility on morning of February 26, 2026, and was placed on AVAPS machine with 3L oxygen.
Interview with licensed Nurse Practitioner (NP) Employee E4, on Wednesday, March 4, 2026, at 11:45 am, revealed she was unaware of physician orders related to frequency of AVAPS application and maintenance of oxygen levels.
The facility's failure to consistently administer and appropriately document life-sustaining AVAPS therapy with physician-ordered oxygen parameters resulted in actual physical harm and significant clinical decline for Resident R3. The facility failed to ensure resident received SpO-2 target of 88% - 92% and failed to apply the AVAPS machine as ordered resulting in the resident's oxygen saturation dropping to a critical level of 60%. This failure resulted in Resident R3 experiencing acute respiratory distress, mental confusion, and elevated CO-2 levels, necessitating an emergency transfer to the hospital on February 25, 2026.
28 Pa Code 211.12(d)(1)(5) Nursing services
| | Plan of Correction - To be completed: 04/21/2026
Preparation and /or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed with federal and state law requirements.
Identification of other residents or areas having the potential to be affected due to the nature of the deficiency:
The deficient practice has the potential to affect all residents.
Corrective action
1.Resident R3's respiratory care was immediately reviewed and updated with the interdisciplinary team, including nursing, respiratory therapy and the medical provider.
2.DON or designee to provide re-education to nursing staff on Proper application of AVAPS, Documentation of use, refusal, Notification of the physician for changes in condition and repeated refusals.
3.DON or designee to review all residents needing CPAP/BIPAP/AVAPS to ensure Proper application of AVAPS, Documentation of use, refusal, Notification of the physician for changes in condition and repeated refusals.
4.DON or designee to audit all residents needing CPAP/BIPAP/AVAPS Weekly X4 Monthly X2 to ensure continued compliance with Proper application of AVAPS, Documentation of use, refusal, Notification of the physician for changes in condition and repeated refusals.
5.Results will be reviewed at the quarterly QAPI meeting
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