Failure to Initiate and Monitor BiPAP Therapy and Respond to Alarms
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident requiring BiPAP therapy. The resident, who had multiple diagnoses including diabetes, heart disease, leukemia, asthma, COPD, and obstructive sleep apnea, was observed on multiple occasions with her BiPAP machine alarming while she was resting in bed. Staff at the nurse's station were unaware of the ongoing alarms, as the alarms were not audible from their location, and could not confirm how long the alarms had been sounding. Additionally, there were no physician orders or care plans in place for the resident's BiPAP or oxygen therapy until after the deficiency was identified. Further observations revealed that the resident's BiPAP machine was not running at a later time, and the resident was unaware of why it was off. Nursing staff were also unaware that the machine was not operating and had not been informed of any issues or refusals regarding the therapy. Review of the BiPAP machine manual and facility policy indicated that alarms should be responded to promptly and that care should be provided per physician orders, which were not in place at the time of the observations.