Failure to Accurately Document Bipap Use on Admission Assessment
Penalty
Summary
The facility failed to provide an accurate assessment that reflected a resident's use of a Bipap machine on her admission Minimum Data Set (MDS). Despite multiple sources of information indicating the resident used a Bipap machine nightly—including the resident's own statements, nursing notes, skilled assessments, and direct observations of the machine at her bedside—the admission MDS did not document this respiratory support therapy. The resident had a history of significant medical conditions, including a displaced bicondylar fracture of the right tibia, diabetes, morbid obesity, and shortness of breath, and was admitted from a short-term general hospital. She was cognitively intact and required moderate assistance with activities of daily living. Interviews with facility staff, including the Director of Nursing (DON), charge nurse, and MDS nurse, revealed a lack of awareness that the resident's Bipap use was not reflected on the admission MDS. The DON and MDS nurse acknowledged that not having this information accurately documented could result in missed care. The facility's records, including the resident's care plan and physician's orders, also did not consistently reflect the use of the Bipap machine, despite its presence and use being confirmed through observations and interviews.