Failure to Monitor and Document Non-Invasive Ventilator Use
Penalty
Summary
The facility failed to monitor and document the use of a non-invasive ventilator (NIV) for a resident with chronic obstructive pulmonary disease (COPD), hypoxemia, and sleep apnea. The resident's care plan included interventions such as applying the NIV machine as ordered, listing settings, monitoring oxygen saturation levels, and contacting the physician as needed. A physician's order specified that the NIV should be applied at bedtime with particular settings, and required staff to monitor and document respiratory rate, minute volume, exhaled tidal volume, and the resident's tolerance. Upon review, there was no documentation in the Medication Administration Records (MARs) or Treatment Administration Records (TARs) of the required monitoring when the NIV was used. The Director of Nursing (DON) explained that the order was entered on a respiratory flowsheet that was not visible to nursing staff, resulting in the absence of documentation. The facility's policy required trained personnel to perform equipment setup, monitoring, and documentation as per physician orders, including detailed respiratory assessments and resident tolerance, which was not completed in this case.