The incident occurred on August 26, 2025, when Resident #1's BIPAP machine stopped working between 2 and 3 AM. Respiratory therapist J placed the resident on regular oxygen instead of retrieving the backup BIPAP machine that all staff knew was available.
BIPAP machines remove carbon dioxide from the body and help residents breathe better. Without the device, residents can experience shortness of breath, and high carbon dioxide levels can cause increased sleepiness, confusion and other health problems.
RT J told inspectors during a November 19 interview that he "was not aware there was a backup BIPAP machine." He said the resident's oxygen saturation levels were fine and there was no shortness of breath. "Had there been an emergency, 911 would have been called," RT J stated.
But other staff contradicted his account.
RT C, who received the morning shift report from RT J, confirmed that all respiratory therapists know about the backup machine. "There is a backup BIPAP machine in the respiratory storage room," RT C told inspectors. "All RTs are aware of the backup BIPAP machine because the BIPAP machine needs to be checked for functionality at the beginning and end of every shift."
The facility requires respiratory therapists to check BIPAP machines twice daily and sign off on a sheet documenting the checks.
RN F, who also received shift report about the incident, said nurses and respiratory therapists receive training on the backup BIPAP machine. "Having a BIPAP machine is a doctor's order and all doctor's orders need to be followed," RN F stated. The machine "helped Resident #1 expand his lungs and prevent desaturation."
The Director of Nursing confirmed during her interview that a backup BIPAP machine was available the night of August 26. "All nurses and RTs were aware of where the back-up BIPAP machine was located," she said.
She dismissed concerns about the incident. "There was no negative outcome because Resident #1 did not have any issues," the DON stated. "There would not have been a negative outcome because nothing happened to Resident #1."
The facility's Administrator expressed confusion about RT J's claim of ignorance. "I did not know why RT J would have said he was not aware there was a back-up BIPAP machine," the Administrator told inspectors. "There is always a back-up BIPAP machine for the reasons of malfunction."
The facility actually had multiple backup options available. The Administrator noted that the facility "also had another machine available that worked as a BIPAP and a ventilator."
His conclusion was direct: "There was no excuse for Resident #1 to not have had a BIPAP machine."
The facility's own policy required notification of circumstances that "require a need to alter treatment," including "discontinuation of current treatment due to adverse consequences." Yet no notification occurred when RT J abandoned the prescribed BIPAP therapy.
RT C explained the medical risks RT J ignored. A resident not using BIPAP "could cause a resident to become short of breath," he said. The carbon dioxide buildup "could cause increased sleepiness, confusion and other health problems."
RT J acknowledged these same risks during his interview. "A negative outcome could have been that Resident #1's respirations levels and saturation levels could have been low, and Resident #1 could have had shortness of breath," he stated.
The inspection found that despite the facility's training requirements, backup equipment availability, and clear policies, RT J failed to provide the doctor-ordered treatment for several hours. The resident required continuous oxygen, nebulizer treatments, and the BIPAP machine as part of his prescribed respiratory care plan.
Federal inspectors cited the facility for failing to ensure the resident received prescribed treatments as ordered by his physician. The violation affected few residents but represented minimal harm or potential for actual harm.
The incident revealed a gap between the facility's stated policies and actual practice, where a respiratory therapist could claim ignorance of basic backup equipment that other staff described as common knowledge requiring twice-daily checks.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hidalgo Nursing and Rehabilitation Center from 2025-11-19 including all violations, facility responses, and corrective action plans.
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