Failure to Provide and Document Prescribed BIPAP Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with chronic hypercapnia who required nocturnal BIPAP therapy. Upon re-admission from the hospital, the resident was supposed to receive BIPAP treatment at night as per hospital discharge instructions. However, there was no evidence in the Medication Administration Record (MAR) or Treatment Administration Record (TAR) that the resident received any BIPAP or CPAP therapy during the specified period. The resident confirmed that BIPAP treatment was only administered in the hospital and not at the facility, and stated that he did not refuse the therapy while at the facility. Additionally, the facility did not have the necessary equipment available for the resident's use. Review of the resident's care plan revealed that it did not include any plan of care for CPAP/BIPAP therapy, despite clear hospital instructions for nightly BIPAP use. There was also no physician order or documentation seeking clarification of the hospital's order for respiratory therapy. Interviews with facility staff, including LPNs, nurse practitioners, and the DON, indicated a lack of communication and follow-through regarding the reconciliation and implementation of the hospital's recommendations. Staff were unclear about their responsibilities for clarifying and carrying out admission orders, and there was no documentation that nursing staff sought clarification on the discrepancy in respiratory treatment orders. Facility policies and job descriptions required nurses to administer and document all treatments as ordered by the physician, including BIPAP/CPAP therapy. Despite these requirements, the resident's records showed no documentation of respiratory care being provided, and staff interviews confirmed that the necessary therapy was not consistently administered or documented. The lack of documentation and failure to implement the prescribed therapy constituted a deficiency in providing appropriate respiratory care as needed.