Inaccurate Documentation of BiPAP Removal on TAR
Penalty
Summary
A deficiency occurred when a nurse inaccurately documented the removal of a resident's BiPAP machine on the Treatment Administration Record (TAR). The resident, who had multiple diagnoses including acute and chronic respiratory failure, congestive heart failure, obesity, end stage renal disease, hypertensive heart disease, sleep apnea, and COPD, was ordered by the physician to use a BiPAP machine during sleep and to have it removed upon waking. On the night in question, the resident became upset, refused medications, broke his cane, and threw the BiPAP machine to the floor, rendering it nonfunctional. The nurse documented in the nurse's note that the resident remained on continuous oxygen via nasal cannula and did not use the BiPAP machine that night. Despite this, the same nurse inaccurately recorded on the TAR that the BiPAP was removed in the morning, as if it had been used as ordered. Interviews with staff, including the DON and the nurse involved, confirmed that the documentation on the TAR did not accurately reflect the care provided, as the BiPAP was not in use and could not have been removed in the morning. The facility's policy requires complete and accurate documentation for each resident, but this was not followed in this instance.