Failure to Provide BIPAP as Ordered Due to Staff Unawareness of Backup Equipment
Penalty
Summary
The facility failed to ensure that a resident who required respiratory care was provided with a BIPAP machine as ordered by the physician. The resident, a male with diagnoses including acute and chronic respiratory failure with hypercapnia, COPD, dependence on supplemental oxygen, obstructive sleep apnea, and pulmonary hypertension, had a physician's order for BIPAP use at night and as needed. On the night in question, the resident's BIPAP machine malfunctioned after being removed for medication administration, and the respiratory therapist (RT) on duty was unable to restore its function. Despite the existence of a backup BIPAP machine in the facility, the RT stated he was not aware of its availability until several hours later, by which time the resident was already asleep. The resident was placed on supplemental oxygen for the remainder of the night. Interviews with other staff, including another RT, a registered nurse, the DON, and the administrator, confirmed that a backup BIPAP machine was available and that staff had been in-serviced on its location and use. Documentation also indicated that the BIPAP machine and backup equipment were to be checked at the beginning and end of each shift, with a sign-off sheet for accountability. The resident did not experience any immediate negative outcomes during the incident, as his oxygen saturation levels remained stable and he did not exhibit shortness of breath. However, the failure to provide the BIPAP machine as ordered constituted a deficiency in following physician orders and ensuring respiratory care consistent with professional standards of practice. The facility's policy required notification and action in circumstances requiring alteration of treatment, such as equipment malfunction, but this was not followed in this instance.