Failure to Follow Physician Order and Address Malfunctioning Bipap Device
Penalty
Summary
The facility failed to follow a physician's order for the use of a Bipap device and did not act in a timely manner when the device was reported as malfunctioning for a resident with significant respiratory conditions. The resident had diagnoses including COPD, acute and chronic respiratory failure, and heart failure, and was ordered to use Bipap nightly with specific settings. Documentation and staff interviews revealed that the Bipap device was not consistently functioning as ordered, with multiple staff noting that the machine would turn off or stop blowing air, and that these issues were not always communicated to the physician or the resident's family. Progress notes indicated that the resident experienced episodes of shortness of breath and complaints of discomfort, with staff at times substituting oxygen via nasal cannula when the Bipap was not working. Despite ongoing issues with the Bipap, there was a lack of timely escalation to the physician or respiratory company, and the care plan did not specify steps to follow in the event of equipment malfunction. The resident's family ultimately provided a backup Bipap device, but the resident continued to exhibit symptoms consistent with hypercapnia and respiratory distress. The resident was eventually transferred to the hospital in respiratory distress, where elevated carbon dioxide levels were confirmed, and ICU admission for Bipap was required. Staff interviews confirmed that the Bipap malfunction was known but not always reported or addressed promptly. The facility's failure to follow the physician's order for Bipap use and to respond appropriately to equipment malfunction resulted in actual harm to the resident, including dyspnea, hypoxemia, and hypercapnia.