Failure to Obtain Orders and Implement Care for BiPAP Use
Penalty
Summary
Facility staff failed to obtain and implement physician orders for the use of a non-invasive ventilator, specifically a BiPAP machine, for a resident diagnosed with congestive heart failure and obstructive sleep apnea. The resident, who was cognitively intact and required assistance with several activities of daily living, had a BiPAP machine at the bedside, but there were no documented orders specifying its use or settings in the resident's medical record. The care plan included a focus on BiPAP therapy, but interventions were limited to encouraging use, without reference to specific orders or settings. Additionally, the facility did not implement the required daily, weekly, and monthly cleaning protocols for the BiPAP machine until several days after the resident's admission. The Unit Manager confirmed that cleaning procedures were not followed initially because the machine belonged to the resident and not the facility. Facility policy outlined specific cleaning requirements for CPAP/BiPAP equipment, but these were not adhered to until after the deficiency was identified.