Failure to Obtain Physician Order for Bipap Use
Penalty
Summary
The facility failed to ensure that a resident who required respiratory care, specifically the use of a Bipap machine at night, received such care in accordance with professional standards and the resident's care plan. The resident, who was admitted with multiple diagnoses including a displaced bicondylar fracture of the right tibia, diabetes, morbid obesity, and shortness of breath, had been using a Bipap machine nightly since admission. Despite this, there was no physician's order for the Bipap documented in the resident's electronic medical record, order summary, or care plan. Multiple observations confirmed the presence and use of the Bipap machine in the resident's room, and interviews with the resident and nursing staff confirmed nightly use of the device. Interviews with the DON and nursing staff revealed that a physician's order is required for treatments such as Bipap, and the absence of such an order was not identified at the time of admission or during subsequent care. The admitting nurse was unaware that the resident had a Bipap machine at the time of admission and did not obtain an order. The facility's policy requires a written physician's order for all treatments, but this was not followed in this case, resulting in the resident using the Bipap without proper medical authorization or documentation.