HospitalInspections.org

Based on medical record review, facility policy review and staff interview, the facility staff failed to follow physician orders and document completion of incentive spirometry in 4 of 4 patients (#1, 5, 9, 10) who had orders in a total of 10 medical records reviewed. This deficient practice has the potential to effect all patients who have orders for incentive spirometry.

Findings include:

Per review on 3/10/14 at 1:30 pm of facility policy titled Incentive spirometer, policy #C01.223, dated 8/4/12 stated in part, A. Gather equipment. I. Document in the Respiratory interventions section of the patient care summary.

Per review with Registered Nurse Educator (RNE) Q on 3/6/14 at 9:25 am of pt. #1's medical record (MR) indicated on 2/2/14 at 2:14 pm a physician order, "Incentive Spirometry to be done every hour while awake", acknowledged by the RN on 2/2/14 at 2:14 pm. No documentation noted that incentive spirometry was completed.

Per review of pt. #1's plan of care documentation dated 2/10/14 at 3:32 pm noted: "Family asking about incentive spirometry. Incentive spirometry order received on 2/2/14 for patient. Patient given incentive spirometry and taught how to use."
Per interview with RN R on 3/10/14 at 1:00 pm, RN R stated R was the nurse who was questioned by the family about using the incentive spirometry and R supplied the incentive spirometry and taught patient how to use on 2/10/14. RN R was not sure why it was not initiated when ordered.
Per review with RNE Q on 3/6/14 at 10:25 am of pt. 5's MR indicated on 2/5/14 at 1:09 am a physician order for "Incentive Spirometry to be done every hour while awake". Order acknowledged by RN on 2/5/14 at 1:09 am. No documentation noted that incentive spirometry was completed.

Per review with RNE Q on 3/6/14 at 11:20 am of pt. #9's MR indicated that on 1/29/14 at 10:23 pm a physician order for "Incentive Spirometry to be done every hour while awake". Order acknowledged by RN on 1/29/14 at 10:23 pm. No documentation noted that incentive spirometry was completed.

Per review with RNE Q on 3/6/14 at 11:40 am of pt. #10's MR indicated that on 1/16/14 at 5:22 pm a physician order for "Incentive Spirometry to be done every hour while awake". Order acknowledged by RN on 2/16/14 at 5:22 pm. No documentation noted that incentive spirometry was completed.

Per interview with RNE Q on 3/6/14 at 3:30 pm RNE Q stated" that when an order for incentive spirometry is obtained the nurse needs to add as an intervention on the care plan. Then it will appear on the patient care summary flow sheet, where the nurses would document that incentive spirometry was completed with the patient." RNE Q stated "this intervention was never added to the flow sheets therefore it is not indicated that it was completed". RNE Q acknowledged that this was a problem.