Failure to Follow Physician Orders for BiPAP Application Due to Missing Equipment
Penalty
Summary
The facility failed to follow physician orders for the application of a BiPAP device for a resident with a history of acute on chronic hypercapnic respiratory failure, COPD exacerbation, and chronic hypoxic respiratory failure. The resident was ordered to use BiPAP during sleep, with staff assistance for setup and documentation of any refusal. However, after a room transfer, a critical component of the BiPAP device (elbow connector) was lost, making the device unusable for two nights. During this period, the resident received oxygen via nasal cannula instead, as per physician orders, but the BiPAP was not applied as ordered. Nursing staff documented in the Medication Administration Record and progress notes that the BiPAP was applied, despite the device being inoperable due to the missing part. The attending physician was not notified about the inability to use the BiPAP, and no alternative respiratory interventions were implemented. The Director of Nursing confirmed that the missing connector was not reported to the physician and acknowledged that documentation inaccurately reflected the use of the BiPAP device.