Failure to Ensure Proper Use of BiPAP Machine for Resident with Sleep Apnea
Penalty
Summary
The facility failed to provide necessary respiratory care services for a resident with a diagnosis of obstructive sleep apnea, type II diabetes mellitus, and asthma. The resident was admitted with a physician's order for a BiPAP machine to be used nightly from 9 p.m. until the resident woke up, or as needed, with supplemental oxygen as ordered. Record review showed that the resident was severely cognitively impaired and required total staff assistance for activities of daily living. The care plan included the use of the BiPAP machine during sleep to maintain normal breathing and prevent complications related to shortness of breath. However, the BiPAP compliance report indicated the resident's average usage was only 2 hours and 16 minutes per night, significantly less than the prescribed duration. Interviews with nursing staff and the DON revealed that the BiPAP machine was frequently leaking and alarming at night, indicating it was not properly set or functioning while on the resident. The night shift nurses were reportedly informed to ensure the BiPAP was properly set, but the issue persisted. The DON stated that nurses should be competent in operating and troubleshooting the BiPAP machine, and the physician confirmed that the resident was not receiving the intended therapy duration. Facility policy required documentation of therapy duration, resident tolerance, and physician notification if the resident refused or experienced adverse consequences, but the report did not indicate these steps were consistently followed.