Failure to Develop and Implement Care Plan for BIPAP Therapy
Penalty
Summary
Licensed nursing staff failed to develop and implement a resident-centered care plan for a resident who required Bilevel Positive Airway Pressure (BIPAP) therapy. The resident was admitted with diagnoses including acute and chronic respiratory failure with hypercapnia, sleep apnea, and morbid obesity. Although a physician ordered BIPAP therapy at bedtime for obstructive sleep apnea, the resident's care plan for altered respiratory status was not updated to include this intervention. Review of facility records confirmed that the care plan did not address BIPAP therapy, and the Medication Administration Record showed the resident did not receive the ordered BIPAP therapy on a specific date due to the equipment being inoperable. Interviews with facility staff confirmed that care plans are intended to address the whole person and should be updated to reflect changes in care needs. The facility's policy requires the interdisciplinary team to develop a comprehensive, person-centered care plan based on the resident's needs. However, the lack of a care plan intervention for BIPAP therapy decreased the facility's ability to provide individualized care and ensure the resident's safety, as the therapy was not administered as ordered.