HospitalInspections.org

Based on interview and record review the facility failed to ensure 3 of 3 patients had complete plan of cares which included oxygen therapy which was ordered by the physician (Patient #s'3, 5 and 6).
This deficient practice had the likelihood to cause harm in all patients presenting to the Emergency Department (ED).
Findings include:

*Review of an ED record on Patient #6 revealed he was a 62 year old male who presented on 03/05/2015 with diagnoses of acute pulmonary edema, myocardial infarction-non ST elevation, hypokalemia, and Hypertensive emergency.
Review of the triage assessment timed 11:56 p.m., revealed Patient #6 appeared distressed, uncomfortable, behavior was agitated, anxious, and restless. The airway was patent, respiratory effort was labored, with retractions; respiratory pattern was tachypnea and shortness of breath at rest.
Review of the vital sign log revealed the following:
At 11:57 a.m. the oxygen saturation was 93 percent on 9 percent simple mask;
At 12:00 a.m.-until 12:25 a.m. the oxygen saturation ranged from 84-92 percent on 6 Liters per minute on a nasal cannula.
At 12:36 a.m-1:54 a.m. the oxygen saturation ranged from 88-98 percent on 15 percent non-rebreather mask.
All of the documentation on the log was by nursing staff and there was no documentation of ABG's (arterial blood gases) on the chart.
Review of the chart revealed no physician order for the different methods and amount of oxygen administered to this patient. There were also no parameters for what level to keep the oxygen saturation at.

*Review of an ED record on Patient #5 revealed she was an 87 year old female who presented on 03/04/2015 at 4:18 p.m., with diagnoses of chest pain, atrial fibrillation-chronic, hyponatremia, and thrombocytopenia.
Review of the vital sign log revealed at 4:27 p.m., Patient #5 had an oxygen saturation of 96 percent on room air.
Review of a nursing assessment timed 4:30 p.m. revealed Patient #5 made complaints of pain in the anterior aspect of the left upper chest and pain does not radiate. Pain currently is 6 out of 10 on a pain scale.
There was no documentation of a physician order or implementation of the oxygen protocol with the presenting diagnoses mentioned on this patient.

*Review of an ED record on Patient #3 revealed she was a 41 year old female who presented on 02/05/2015 with a diagnosis of shortness of breath.
Review of a triage assessment at 1:50 p.m. revealed Patient #3 had an oxygen saturation of 100 percent on room air. At 2:15 p.m. there was documentation oxygen was being administered via nasal cannula at 2 Liters/minute. At 3:41 p.m., the oxygen saturation was still at 100 percent on room air and there was no mention of the oxygen therapy.
Review of the chart revealed no physician orders for oxygen therapy on Patient #3.
During an interview on 03/10/2015 after 12:00 p.m., Staff #1 confirmed the problem with lack of physician orders for oxygen therapy.

Review of the policy named "Oxygen Protocol" dated 05/2013 revealed the following:
It will be the policy of (name of the facility) to provide safe and timely administration of oxygen to all patients requiring interim or long term support. Oxygen will be administered to patients on the order of a physician or in emergent conditions that require immediate response to stabilize the patient. Oxygen will be titrated by the Cardiopulmonary Depart. Unless otherwise ordered by the physician.
1. Review chart for:
a. Physician order
b. Diagnosis and history
c. ABG results if available
2. a. Before starting oxygen therapy, when possible, obtain initial oxygen saturation.
b. If the SpO2 is (greater than or equal) to 92 % oxygen will be placed on standby unless one of the following conditions exist:
1. If the patient is Cardiac in nature and symptomatic. (chest pain)
2. If the patient has COPD and is a chronic home oxygen user.
3. If the patient is post operative for the first 12-24 hours.
4. If the physician orders (No Protocol)

3. e. Oxygen will only be discontinued by the physician or per protocol.
4. a. Patient with COPD may be sensitive to high oxygen concentrations resulting in CO2 retention and in severe cases CO2 narcosis resulting in cessation of breathing.
b. In patients with severe retention of CO2, a SpO2 of 88-92 % will be maintained unless otherwise ordered by the physician.
c. The physician may stop the protocol any anytime by writing a (No Protocol) order
d. The physician may also establish his/her own maintenance levels for SpO2.
f. If a patient requires an increase of Oxygen or change in device to maintain an adequate saturation the physician must be notified.