Failure to Provide Timely BiPAP Respiratory Support Upon Admission
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease and chronic hypoxic hypercapnic respiratory failure was not provided with a BiPAP machine as required for their respiratory care. The resident's hospital discharge summary and admission pre-screen both documented the need for nightly BiPAP use with specific settings, and this information was communicated to facility leadership via email prior to admission. However, upon admission, the BiPAP machine was not available, and there was no physician's order for the BiPAP at that time. The baseline care plan and nursing documentation did not indicate the need for BiPAP, and the resident was only placed on oxygen via nasal cannula. Multiple staff interviews and record reviews revealed that the need for BiPAP was overlooked during the admission process, with confusion among staff regarding responsibility for ordering the equipment. The admission screener communicated the requirement to the DON, Health Information Manager, and Administrator, but the email was not read or acted upon. Nursing staff documented the absence of the BiPAP machine over several days, and the equipment was not available in the facility until five days after admission, despite repeated documentation and verbal communication among staff about its absence. During this period, the resident did not receive the prescribed BiPAP therapy and was eventually found to be lethargic, only responding to verbal stimuli, and was transferred to the hospital for evaluation. The deficiency was attributed to failures in communication, documentation, and adherence to professional standards of practice and facility policy regarding the provision of necessary respiratory equipment upon admission.