Failure to Implement and Monitor Physician-Ordered Oxygen and BIPAP Therapy
Penalty
Summary
A resident with a history of chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypercapnia, and a left pneumonectomy was admitted to the facility and required oxygen therapy and BIPAP at night per physician orders. The resident's care plan included specific interventions such as administering oxygen as ordered, using BIPAP with prescribed settings at bedtime and as needed, and monitoring for signs of respiratory distress. Upon return from a hospital stay, the resident's discharge instructions reiterated the need for 3L oxygen via nasal cannula during the day and BIPAP overnight, with encouragement for nightly BIPAP use. Despite these orders, facility records did not show evidence that the BIPAP was administered as prescribed during the night following the resident's return from the hospital. Nursing documentation failed to indicate that the resident refused BIPAP, and interviews with the resident and family contradicted any claims of refusal. The BIPAP machine was reportedly present in the room, but staff did not attempt to place it on the resident, nor did they ask the resident about its location or encourage its use. Additionally, vital signs and oxygen saturation were not monitored throughout the night, and there was no assessment for symptoms such as fever, shortness of breath, or lethargy, despite the resident's high risk for respiratory complications. The following morning, the resident was found in a deteriorated state with low oxygen saturation and was subsequently sent to the emergency department, where she was diagnosed with acute hypoxic hypercapnic respiratory failure. Interviews with staff revealed confusion about the location and use of the BIPAP machine, lack of follow-up on highlighted physician orders, and failure to notify the nurse practitioner when the BIPAP was not available. Facility policy required timely and appropriate care for changes in condition and adherence to physician orders for oxygen therapy, but these were not followed, resulting in a failure to provide safe and appropriate respiratory care as needed.