Failure to Provide Prescribed BiPAP Therapy Due to Broken Equipment and Lack of Timely Notification
Penalty
Summary
A resident with chronic respiratory failure, obstructive sleep apnea, and chronic obstructive pulmonary disease (COPD) was ordered to receive bilevel positive airway pressure (BiPAP) therapy at bedtime, along with continuous oxygen. The resident's care plan and physician orders specified the use of BiPAP and regular checks of the device. However, from mid to late February, the BiPAP device was not administered as it was documented as broken, and the resident did not receive the prescribed therapy during this period. During this time, the resident experienced a decline in condition, including lethargy, slow response, shortness of breath, bradycardia, and hypoxia. The nurse practitioner was informed that the resident had not used the BiPAP device in recent days due to it being broken, and subsequently ordered a hospital transfer for evaluation. Hospital records confirmed the resident had not used the BiPAP device for three days and was admitted with an acute exacerbation of COPD, sepsis, and lower respiratory tract infection. Interviews revealed that staff, including nursing and purchasing, were aware of the broken device but did not promptly notify the physician or respiratory therapy. The DON confirmed there was no plan in place for the resident in the absence of the BiPAP device, and the physician was not informed until after the resident's condition had worsened. The respiratory therapy director and physician both stated they should have been notified immediately to address the interruption in care.