King David Nursing and Rehabilitation Center admitted the patient on March 28, 2025, from a hospital stay. The resident's diagnoses included obstructive sleep apnea and acute respiratory failure with hypercapnia — dangerously high levels of carbon dioxide in the blood.
The hospital discharge summary was explicit about post-discharge care: continue weaning off supplemental oxygen, maintain oxygen support in the meantime, and continue CPAP at night. CPAP machines deliver steady airflow through a mask to keep airways open during sleep, preventing the breathing interruptions that define sleep apnea.
But the facility's attending physician failed to write orders matching the hospital's discharge plan.
Upon admission, the doctor ordered only "Oxygen inhalation via nasal cannula at 2 liters per minute." No CPAP order. No oxygen weaning plan.
Three days later, on March 31, the attending physician documented the resident's medical history in a visit note: "Continue with O2 by nasal cannula. Monitor respiratory status. History of obstructive sleep apnea. Continue with CPAP."
Still no actual CPAP order was written.
The note made no mention of weaning the resident off supplemental oxygen, as the hospital had directed, nor any rationale for ignoring that part of the discharge plan.
On April 9 — nearly two weeks after admission — the physician finally wrote an order to "Wean off O2." The order provided no target oxygen saturation level for staff to follow during the weaning process.
Six days later, on April 15, another physician note acknowledged the resident's sleep apnea history: "Respiratory status seems to be at baseline. No dyspnea on examination. Continue with CPAP."
Again, no CPAP order followed the documentation. The note said nothing about the resident's progress weaning off oxygen or how well they were tolerating the process.
It wasn't until May 1 — more than a month after admission — that the physician finally wrote orders for "C-Pap on at night for OSA."
Federal inspectors interviewed the Director of Nursing on September 16 about how the facility reconciles hospital discharge plans with admission orders. She explained that physicians review discharge instructions when they're in the building, or nurses call doctors to review plans by phone if physicians aren't on-site.
When asked specifically why Resident #8's admission orders ignored the hospital's CPAP and oxygen weaning instructions, the nursing director said she wasn't sure and would need to check the record. She promised to get back to the surveyor with an explanation.
No further information was provided before inspectors completed their review.
The case illustrates a breakdown in the handoff between hospital and nursing home care — a critical transition point where communication failures can leave residents without prescribed treatments. Sleep apnea, particularly when combined with respiratory failure, requires consistent treatment to prevent serious complications.
CPAP therapy is considered the gold standard treatment for obstructive sleep apnea. Without it, patients experience repeated breathing interruptions throughout the night, leading to fragmented sleep, drops in blood oxygen levels, and increased strain on the cardiovascular system.
For someone already dealing with acute respiratory failure and elevated carbon dioxide levels, delays in CPAP treatment could compound breathing difficulties and slow recovery.
The inspection found this problem affected one of eight residents reviewed for quality of care issues. The facility's administrator was notified of inspectors' concerns on September 17, the day before the inspection concluded.
Federal regulations require nursing homes to provide care according to physician orders and to ensure residents receive appropriate treatment for their diagnosed conditions. The failure to implement hospital discharge instructions represents a gap in care coordination that left a vulnerable resident without prescribed respiratory support for weeks.
The resident's medical record showed a pattern of documentation acknowledging the need for CPAP therapy in physician notes, while actual orders for the treatment went unwritten. This disconnect between clinical recognition and formal orders meant nursing staff lacked the authorization to provide the prescribed care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for King David Nursing and Rehabilitation Center from 2025-09-18 including all violations, facility responses, and corrective action plans.
Additional Resources
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