Failure to Ensure BiPAP Orders and Implementation After Hospitalization
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a BiPAP order was in place and implemented for a resident with a history of acute and chronic respiratory failure, COPD, and hypercapnia after returning from the hospital. The resident's care plan and hospital discharge orders specified the need for BiPAP therapy with specific settings, but upon review, there was no current physician's order for BiPAP, and the Medication Administration Record (MAR) did not reflect any BiPAP orders or documentation of its use for the relevant months. Staff interviews confirmed the absence of orders and documentation, and there was no record of resident refusals or consistent application of the BiPAP therapy as prescribed. The resident experienced episodes of respiratory distress, including an incident where she was found with an oxygen saturation of 38% and required emergency transfer to the hospital, where she was intubated for acute hypercapnic respiratory failure. Documentation from the BiPAP machine indicated several nights when the resident did not use the device, but there was no documentation explaining these gaps or indicating whether the resident refused therapy. Staff, including the DON and Respiratory Supervisor, were unable to provide evidence that the BiPAP was consistently applied or that refusals were documented. The lack of a current physician's order, absence of documentation in the MAR and progress notes, and failure to clarify or implement the recommended BiPAP settings after hospital discharge directly contributed to the resident's respiratory compromise and subsequent hospitalization. The deficiency affected one resident out of three reviewed for oxygen therapy in a facility with a census of 40.