Failure to Follow Physician Order for Nightly BiPAP Use
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order for nightly BiPAP use for a resident requiring respiratory support. The resident, an older adult with multiple diagnoses including COPD with acute exacerbation, asthma, dependence on supplemental oxygen, hypertension, hyperlipidemia, benign prostatic hyperplasia, syncope and collapse, and prediabetes, had a physician order dated 2/12/26 for BiPAP settings of 20/7 with an oxygen blend of 25–30% FiO2 to maintain pulse oximetry at 92–94%, using a full face mask every night with staff assistance to apply the device. A nurse practitioner progress note dated 2/12/26 documented that the resident did not receive his BiPAP machine. Review of the Medication Administration Record for the month showed the BiPAP order as written but documented as not administered from 2/12/26 through 2/15/26, with the DON explaining that a “9” on the MAR indicates not given/not administered. During interview, the LPN unit manager confirmed the physician’s BiPAP order but stated she was unsure whether the resident actually received the BiPAP. The facility was unable to provide a policy on following physician orders and only produced a BiPAP policy stating that respiratory therapy/nurses oversee initiation and delivery of BiPAP and must verify the physician order and document appropriately, without evidence that these steps were carried out for this resident during the identified dates.
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