Failure to Provide Timely BiPAP Respiratory Support as Ordered
Penalty
Summary
The facility failed to provide a resident with a physician-ordered BiPAP machine for respiratory support, despite multiple hospital discharge orders specifying the need for BiPAP at specific settings. The resident, who had a history of acute diastolic congestive heart failure, chronic obstructive pulmonary disease with acute exacerbation, acute and chronic respiratory failure with hypoxia, primary pulmonary hypertension, obstructive sleep apnea, and severe cognitive impairment, was admitted and readmitted to the facility several times. Each time, hospital discharge documentation included orders for BiPAP at night, but the facility's admission assessments and electronic medication and treatment administration records did not consistently reflect these orders, and the BiPAP was not made available to the resident in a timely manner. The resident's family provided a CPAP machine from home, but after a hospitalization, the discharge orders were changed to BiPAP, which was not immediately available upon the resident's return to the facility. There was a delay of several days before the BiPAP machine was delivered by the DME provider, during which time the resident did not have access to the prescribed respiratory support. Documentation showed inconsistent entries regarding the use of CPAP or BiPAP, and the care plan did not reflect BiPAP use until well after the resident's return from the hospital, despite clear orders from the hospital for its use. Interviews with the resident's power of attorney, physician, and the facility's Director of Nursing confirmed that there was confusion and a lack of clarity regarding the respiratory device orders, as well as delays in obtaining the correct equipment. The physician and DON acknowledged that the BiPAP should have been available from the initial admission based on the hospital orders, and that the orders should have been clarified and entered into the eMAR. The failure to provide the BiPAP as ordered resulted in the resident being hospitalized for respiratory failure due to not using the BiPAP machine.