Failure to Follow Physician Orders for BiPAP Therapy
Penalty
Summary
Facility staff failed to follow physician orders for BiPAP therapy for one discharged resident. Facility policies required that a physician or other qualified practitioner provide written and/or verbal admission orders for residents’ immediate care and that oxygen, including BiPAP, be administered consistent with professional standards, the care plan, and resident goals and preferences. The resident, who had diagnoses including cancer, hypertension, and COPD, had a physician order dated 11/12/25 for BiPAP at hours of sleep at present parameters at bedtime with removal per schedule, with a start date of 11/13/25. A subsequent order dated 11/13/25 specified BiPAP at hours of sleep at present parameters of 45% and 6.0 cm H2O, with removal per schedule. Review of the Treatment Administration Record for November 2025 showed that the ordered BiPAP treatment was not provided on three occasions: 11/12/25, 11/19/25, and 11/20/25. During an interview, an RN stated that the BiPAP was not applied until 11/13/25, explaining that although the orders were entered on 11/12/25, the treatment was not scheduled until 11/13/25. When asked about a “9” notation on the TAR for 11/19/25 and 11/20/25, the RN stated it meant “see nursing note,” but confirmed there were no corresponding nursing notes to explain why the BiPAP was not used on those dates. This established that staff did not follow the physician’s BiPAP orders and did not document reasons for the missed treatments.
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