HospitalInspections.org

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Based on interview and record review, the hospital failed to ensure that health care providers entered orders for respiratory care in the patient's electronic medical record for 5 of 9 patients reviewed (Patients #1, #2, #3, #4, #5).

Failure to write orders for respiratory care risks medical errors and adverse patient outcomes.

Findings included:

1. Review of the electronic medical records of five patients who expired during their hospitalization showed the following:

a. Patient #1 was a 55 year-old patient who had been admitted to the hospital on 03/22/19 for treatment of injuries following a fall and chronic alcohol abuse. The patient experienced difficulty breathing on 03/23/19 at 10:23 AM and was placed on a BiPAP (bilevel positive airway pressure) machine for breathing assistance. Review of the patient's medical record showed that there was no order written by the patient's healthcare provider for use of the BiPAP machine and for the machine settings.

b. Patient #2 was a 79 year-old patient who had been admitted to the hospital on 03/19/19 for treatment of encephalopathy, septic shock, and pleural effusion. The patient experienced respiratory failure on 03/19/19 at 8:20 PM and was placed on a mechanical ventilator for breathing assistance. Review of the patient's medical record showed that there was no order written by the patient's healthcare provider for use of the ventilator and for the machine settings.

c. Patient #3 was an 88 year-old patient who had been admitted to the hospital on 03/21/19 for treatment of shortness of breath. The patient was placed on a BiPAP machine for breathing assistance on 03/22/19 at 5:00 AM. Review of the patient's medical record showed that there was no order written by the patient's healthcare provider for use of the BiPAP machine and for the machine settings.

d. Patient #4 was a 93 year-old patient who had been admitted to the hospital on 03/19/19 for treatment of sepsis related to a ruptured appendix. The patient experienced shortness of breath and was treated with oxygen 2 liters per minute via nasal cannula beginning 03/26/19 at 10:00 PM. Review of the patient's medical record showed that orders for oxygen therapy were not written by the patient's healthcare provider until 03/28/19 at 1:57 PM.

2. On 07/25/19 at 9:20 AM during a telephone interview with the investigator, the hospital's respiratory therapy manager (Staff #1) stated that orders for ventilator and BiPAP settings should be entered in the patient's medical record.

3. On 07/24/19 at 10:20 AM during an interview with the investigator, the hospital's Quality Consultant (Staff #2) confirmed that the records above did not include written orders for respiratory care.

4. Review of the records of three patients currently receiving care at the hospital showed the following:

Patient #5 was a 50 year-old patient who had been admitted to the hospital on 07/18/19 for treatment of chronic obstructive pulmonary disease. Review of the patient's medical record showed that on 07/25/19 at 5:10 AM the patient was treated with oxygen 5 liters per minute. The record showed that on 07/25/19 at 7:52 AM, the patient was being treated with BiPAP. The record showed that on 07/25/19 at 11;11 AM the patient was being treated with oxygen 4 liters per minute. The patient's medical record did not include written orders for oxygen therapy or use of a BiPAP machine.

5. On 07/25/19 at 1:30 PM during an interview with the investigator, the Director of Medical Surgical Services (Staff #3) confirmed that the record above did not include written orders for respiratory care.
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