Failure to Notify Physician of Inoperable BIPAP and Missed Diabetes Medication
Penalty
Summary
A deficiency occurred when a licensed nurse failed to notify the physician after a resident's BIPAP machine became inoperable, resulting in the resident not receiving the ordered BIPAP therapy. The resident, who had diagnoses including acute and chronic respiratory failure with hypercapnia, type 2 diabetes, sleep apnea, and morbid obesity, was instead provided with oxygen via nasal cannula. There was no documentation that the physician was informed of the BIPAP issue, despite facility leadership and the physician stating that such notification was expected. Additionally, the same resident did not receive a scheduled dose of Ozempic®, a medication prescribed for diabetes management, because the medication was not available. The medication administration record and progress notes confirmed the missed dose, and interviews with staff and the physician indicated that the physician was not notified of the omission. The facility's policies required medication administration in accordance with prescriber orders, but there was no policy specifically addressing physician notification for medication errors or omissions. Interviews with the DON, ADON, and licensed nurse confirmed the missed BIPAP therapy and medication dose, as well as the lack of physician notification in both instances. The DON acknowledged the importance of notifying the physician about missed medications and high-risk medication omissions, but also stated that discretion was left to the licensed nurse. The facility's documentation and staff interviews confirmed that the required notifications did not occur.