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Based on the review of the facility's policies and procedures and medical records and interviews with the staff, it was determined the facility failed to ensure the nursing staff followed the physician's orders for incentive spirometers, vital signs, and follow the policies for intake and output (I&O) for each patient. This affect medical record (MR) #s 150488, 149169 and 429328.

Findings include:

Facility Policy Titled: Care and Removal of Jackson Pratt and Hemovac, Drains
Number 229
Revised 12/09

Procedure for Care of Drains

Equipment
...Container for measuring drainage

6. Empty the collector at the end of each shift (unless contraindicated). Make sure that the drain remains compressed at all times (unless contraindicated).

Documentation
2. Record amount of drainage on intake and output (I&O) sheet
3. Record color and consistency of collected drainage

Facility Policy
Post-Operative Care
Number 198
Revised 12/09

Guidelines
3. Routine post-op vital signs for patients receiving a general anesthetic and spinal anesthesia should begin on return to the unit:
a. Blood pressure, pulse and respirations: every 15 minutes for one hour; every 30 minutes for one hour; every hour for 4 hours; then, every 4 hours for 24 hours.
b. Temperature every 4 hours for 24 hours. If the temperature is above 100 degrees orally, continue checking every 4 hours until afebrile for 24 hours.

1. MR # 150488 was admitted to the facility on 7/19/10 with diagnoses including Degenerative Joint Disease and underwent a Total Hip Replacement of the Right Hip on 7/19/10.

Review of the Total Post-Op Orders dated 7/19/10 revealed orders Routine Post-Op vital signs and I&O every 8 hours.

Review of the I&Os dated 7/19/10 at 15:00 to 7/21/10 01:05 revealed 1 entry for the Hemovac drainage on 7/20/10 at 14:58 which included 90 cc (cubic centimeters).

An interview was conducted on 8/10/11 at 1:40 PM with Employee Identifier (EI) # 4, Registered Nurse (RN), Director of Neurology, confirmed the Hemovac should have been emptied at the end of each shift and the amount and color of drainage should have been documented.

Review of the Procedure Comments dated 7/19/10 revealed documentation the patient received General Endotracheal Anesthesia for the Total Hip Replacement.


Review of the nurses' documentation for vital signs revealed no documentation of a blood pressure, heart rate, respiration or temperature after 7/20/10 at 14:10. The vital signs should have been checked every 4 hours until 21:10 on 7/20/10.

Review of the nurses' documentation dated 7/20/10 at 21:00 revealed the patient was found unresponsive and a code was called. The patient was moved to the Critical Care Unit on a ventilator and expired on 7/21/10 at 5:35 AM.

An interview was conducted on 8/10/11 at 1:35 PM with EI # 1, Quality Outcomes Coordinator who confirmed the there was no documentation of a blood pressure, heart rate, respiration or temperature after 7/20/10 at 14:10 and the vital signs should have been checked every 4 hours until 21:10 on 7/20/10.

2. MR # 149169 was admitted to the facility on 8/8/11 with diagnoses including Osteoarthritis Right Shoulder and under went surgery on the right shoulder on 8/8/11.

Review of the Post-Op Orders dated 8/8/11 revealed orders for an Incentive Spirometry every 4 hours times 48 hours.

An observation of the patient was conducted on 8/9/11 at 2:35 PM by the surveyor with EI # 2, the Director of Quality. Upon entering the room the surveyor asked the patient and family if they had an incentive spirometer and the response was, " no".

EI # 1 then looked in the computer system to identify documentation the incentive spirometer had been given and taught to the patient/family by the nursing staff and none could be found.

An interview was conducted on 8/10/11 at 1:35 PM with EI # 3, Registered Nurse (RN), Clinical Nurse Specialist, who verified the Incentive Spirometers had been the responsibility of Respiratory Services until April 2011 when it became the responsibility of Nursing Services.

3. MR # 429328 was admitted to the facility on 8/8/11 with diagnoses including Degenerative Joint Disease/Right Hip and under went a right hip replacement on 8/8/11.

Review of the Post-Op Orders dated 8/8/11 revealed orders for an Incentive Spirometry every 4 hours times 48 hours.

An observation of the patient was conducted on 8/9/11 at 12:35 PM. Upon entering the room the surveyor asked the patient and family if they had an incentive spirometer and the response was, " no".

EI # 1 then looked in the computer system to identify documentation the incentive spirometer had been given and taught to the patient/family by the nursing staff and none could be found.

Based on review of the facility's policies and procedures and medical records and interviews with the staff, it was determined the facility failed to ensure the respiratory department followed the physicians' orders for incentive spirometers in 3 of 3 closed records reviewed. This affect medical record (MR) #s 150488, 161816 and 62171.

Findings include:

Facility Policy Title: Incentive Breathing

Policy:

The Respiratory Therapist should utilize the following Incentive Breathing Protocol when a physician orders for Incentive Breathing.

Purpose:

The purpose of Incentive Breathing is to prevent or correct Pulmonary Atelectasis.

Procedure

1. Non-Critical Care Patients

a. Patient and family if possible should be educated and instructed on the use of the Incentive Breathing device and to obtain volume goals with each breath times 10 breaths each session.

b. The patient should be instructed to perform these exercise sessions on his/her own at least four times a day if not more frequent and to always cough afterwards.

Clinical Responsibilities:

I. Respiratory Therapist should document the following with each Incentive Breathing treatment in the patient's medical record: Incentive Capacity achieved, number of times performed, breath sounds pre and post therapy, effective cough productive and non productive. Education should also be documented.

II. The Respiratory Therapist should communicate goals and frequency of Incentive Breathing with the patient's nurse to include visual reminder posted in the patient's room.

1. MR # 150488 was admitted to the facility on 7/19/10 with diagnoses including Degenerative Joint Disease and underwent a Total Hip Replacement of the Right Hip on 7/19/10.

Review of the Post-Op (Operative) Orders dated 7/19/10 revealed orders for an Incentive Spirometer q (every) 4 h (hours) while awake times 48 hours.

Review of the Respiratory Therapy flowsheet dated 7/19/10 at 17:46 revealed documentation of the therapist using the Incentive Spirometer. There was no documentation of instruction on use every 4 hours with volume goals with each breath times 10 breaths each session and to always cough afterwards.

An interview was conducted on 8/10/11 at 1:35 PM with Employee Identifier (EI) # 1, the Quality Outcomes Coordinator who verified the above.

2. MR # 161816 was admitted to the facility on 7/17/10 with diagnoses including Left Hip Fracture. Patient under went a Hip Replacement on 7/20/10.

Review of the Post-Op (Operative) Orders dated 7/20/10 revealed orders for an Incentive Spirometer q4h while awake times 48 hours.

Review of the Respiratory Therapy flowsheet dated 7/19/10 at 18:00 revealed documentation of the therapist using the Incentive Spirometer. There was no documentation of instruction on use every 4 hours with volume goals with each breath times 10 breaths each session and to always cough afterwards.

Review of the Respiratory Therapy flowsheet dated 7/22/10 at 08:42 revealed documentation of the therapist using the Incentive Spirometer. There was no documentation of instruction on use every 4 hours with volume goals with each breath times 10 breaths each session and to always cough afterwards.

There was no documentation of the use of an Incentive Spirometer between 7/19/10 at 18:00 and 7/22/10 at 08:42.

An interview was conducted on 8/11/11 at 10:25 PM with EI # 1 who verified the above.



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3. MR # 62171 was admitted to the facility on 7/16/10 with diagnoses including Degenerative Joint Disease and under went a Right Total Knee Arthoplasty on 7/16/10. Review of the Post-Op Orders dated 7/16/10 revealed orders for an Incentive Spirometer q 4 h while awake times 48 hours.

Review of the Respiratory Therapy flowsheet dated 7/16/10 at 16:40 revealed documentation of the therapist using the Incentive Spirometer. There was no documentation of instruction on use every 4 hours with volume goals with each breath times 10 breaths each session and to always cough afterwards. The patient was discharged on 7/19/10. There was no other documentation regarding the use of the incentive incentive spirometer during the patient's hospital stay.

An interview was conducted on 8/10/11 at 1:35 PM with EI # 3, Registered Nurse (RN), Clinical Nurse Specialist, who verified the Incentive Spirometers had been the repsonsibility of Respiratory Services until April 2011 when it became the responsibility of Nursing Services.

An interview was conducted on 8/11/11 at 10:25 AM with EI # 1, who verified the above findings.