Failure to Provide Timely Respiratory Care for Resident
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident who required BiPAP support. The resident, who had a history of chronic obstructive pulmonary disease, diabetes, and heart failure, was readmitted to the facility with a new order for a BiPAP machine. However, the facility did not include this order in the resident's care plan or physician orders until several months later, despite the BiPAP being delivered and the resident having a diagnosis of obstructive sleep apnea. The deficiency was confirmed through interviews with the Licensed Practical Nurse Assessment Coordinator and the Director of Nursing, who acknowledged that the resident's BiPAP usage was not documented in the Minimum Data Set assessments until months after the resident began using the device. This oversight resulted in a failure to provide respiratory care in accordance with professional standards and the resident's care plan.
Plan Of Correction
1. R22's medical records and update the care plan to accurately reflect the diagnosis and physician's orders regarding the use of BiPAP, including the specific settings and conditions. 2. For use and to include "like" residents, the care plans of "like" residents using BiPAP or CPAP will be reviewed to ensure they are current and accurately reflect the diagnoses, physician's orders, and any other pertinent treatment information. 3. The Director of Nursing/Designee will provide comprehensive retraining for registered and licensed nursing on the proper procedures for verifying physician's orders, setting up, using, and monitoring respiratory care equipment including BiPAP machines and its maintenance and care. 4. Audits checks for accuracy in the documentation, proper functioning and regular maintenance of respiratory care equipment, and adherence to physician's orders will be conducted weekly for two weeks, then monthly for two months. 5. The Director of Nursing/Designee will develop a checklist for respiratory care that includes verification of physician's orders, equipment checks, and resident assessments to be completed and signed by the attending staff weekly for four weeks, then monthly for two months. 6. The Director of Nursing/Designee will establish a protocol for immediate communication between staff and physicians when discrepancies or changes in resident care occur, ensuring timely updates to care plans and treatment orders. 7. The Director of Nursing/Designee will regularly update residents and their families about their care status and any changes in treatment plans, particularly regarding respiratory care needs. 8. Updates on the progress of the implemented changes will be reviewed during the Quality Assurance Performance Improvement meetings.