Failure to Update Care Plan for Resident's Bipap Use and Respiratory Needs
Penalty
Summary
The facility failed to ensure that a comprehensive, person-centered care plan was reviewed and revised by the interdisciplinary team after each assessment for a resident who required a Bipap machine at night. Despite multiple observations and interviews confirming the resident's nightly use of the Bipap machine, this need was not reflected in the resident's comprehensive care plan or the Minimum Data Set (MDS) assessment. The resident's diagnosis of shortness of breath was also omitted from the care plan, and there was no physician's order for the Bipap documented in the medical record. Nursing assessments and notes indicated the use of respiratory support, but this information was not incorporated into the care planning process. Staff interviews revealed a lack of awareness among the interdisciplinary team regarding the resident's use of the Bipap machine, with the MDS nurse and admitting nurse both stating they were unaware of this need at the time of care plan development. The Director of Nursing acknowledged that the omission of the Bipap from the care plan could result in missed care. Facility policy requires individualized care plans with measurable objectives and timetables to address all resident needs, but this was not followed in this case.