Failure to Notify Physician of Missed BiPap Administration
Penalty
Summary
Facility staff failed to notify a resident's physician when the resident's BiPap therapy was not administered on three separate occasions, as documented in the October 2025 Treatment Administration Record. The resident, who had a history of acute and chronic respiratory failure with hypercapnia, was admitted with physician orders for BiPap use at bedtime and as needed for naps. The hospital discharge summary emphasized the critical importance of BiPap use for this resident due to their history of respiratory failure and CO2 retention. Despite missed BiPap administrations on 10/3, 10/11, and 10/12/25, there was no documentation in the nursing notes indicating that the physician was notified of these omissions. Interviews with the resident's physician and the Director of Nursing confirmed that the expected notification did not occur.