Failure to Provide Timely BiPAP Therapy for Resident with Chronic Respiratory Failure
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with professional standards of practice for a resident requiring a BiPAP device. The resident, who had a diagnosis of chronic respiratory failure with hypoxia, was readmitted to the facility with physician discharge instructions and orders specifying the need for BiPAP use during naps and nightly. However, review of the treatment administration record showed no evidence that the BiPAP was administered for several days following readmission. Progress notes indicated that the resident's condition worsened, with symptoms such as shortness of breath and cough, due to the lack of BiPAP therapy. Nursing staff and nurse practitioners confirmed that the BiPAP machine was not available or adjusted for use until several days after the resident's return, and the Director of Nursing Services acknowledged that the device was not provided as ordered within the expected timeframe. The deficiency was identified through record review and staff interviews, which confirmed the delay in providing the prescribed respiratory care.