Failure to Document BiPAP Application for Resident on Oxygen Therapy
Penalty
Summary
Licensed nurses failed to consistently document the application of BiPAP therapy at bedtime for a resident with multiple respiratory and cardiac diagnoses, including chronic respiratory failure with hypoxia, congestive heart failure, chronic obstructive pulmonary disease, obstructive sleep apnea, chronic pulmonary edema, and dependence on supplemental oxygen. The physician's order specified that BiPAP should be applied at bedtime, and the facility's policy required documentation of the time BiPAP was started and notification of the physician if the resident refused the procedure. Record review revealed multiple dates over several months where there was no documentation of BiPAP application in the resident's Respiratory Administration Record. During an interview, the DON confirmed that if the application was not documented, it was considered not done, and acknowledged that licensed nurses were expected to initial the record to confirm BiPAP application as ordered. The lack of documentation indicated a failure to provide respiratory care consistent with professional standards of practice.