Failure to Provide Prescribed BIPAP Therapy and Care Planning for Obstructive Sleep Apnea
Penalty
Summary
A resident with diagnoses of obstructive sleep apnea and chronic respiratory failure did not receive their prescribed BIPAP therapy for five consecutive days. The resident reported to staff that her CPAP mask was broken and that she did not have her CPAP placed on the previous night. Upon investigation, staff did not verify the status of the machine or ensure its availability in the resident's room. The BIPAP machine, which was specific to the resident's physician orders, was found in storage after the resident's recent hospital stay, and had not been set up or used. The resident's care plan did not include interventions for obstructive sleep apnea or the use of the BIPAP machine, and there was no documentation of assessment regarding the resident's use or refusal of the device. Staff interviews revealed a lack of awareness regarding the resident's need for the BIPAP machine and the absence of a care plan addressing this need. The respiratory director confirmed that the machine had not been set up and that the resident had not refused its use. The care plan coordinator acknowledged that there was no individualized plan of care for the resident's obstructive sleep apnea or BIPAP use, and that she was unaware of the five-day period during which the resident did not have access to the prescribed therapy. Facility policy requires that physician orders be followed, but in this case, the order for nightly BIPAP use was not implemented.