Failure to Update Respiratory Care Plan After Discontinuation of BiPAP
Penalty
Summary
The facility failed to update the respiratory care plan for a resident after physician orders discontinued the use of a BiPAP machine. Despite the discontinuation order dated 10/15/24, the resident's care plan continued to include interventions for BiPAP use, and the machine remained present in the resident's room. Multiple observations over several days confirmed the BiPAP machine and its tubing were still at the bedside, with the mask stored in a drawer. Staff interviews revealed that the night supervisor believed the BiPAP was still being applied at night, although there were no active physician orders for its use. The MDS coordinator acknowledged that the care plan interventions for the BiPAP were only resolved months after the discontinuation order, and the DON confirmed the machine was left in the room due to family circumstances, but staff were not to administer it without an order. The resident involved had diagnoses including heart failure and insomnia, was severely cognitively impaired, and did not exhibit shortness of breath or require respiratory therapy according to recent assessments. The facility's policy required ongoing assessment and timely revision of care plans as resident conditions changed, but this was not followed in this case, resulting in outdated care plan interventions for respiratory therapy that no longer reflected the resident's current physician orders or needs.