HospitalInspections.org

Based on facility policy and procedure review, equipment operating manual review, medical record review, facility document review and staff interviews, the respiratory staff failed to ensure patient care needs were met by failing to store respiratory equuipment according to Operating Instruction Manual; educate staff on the use of Vapotherm respiratory equipment; and document patient reassessments for 1 of 1 patients on the Vapotherm Precision Flow machine. (Patient #8).

The findings include:

Review of facility policy "RESPIRATORY CARE OXYGEN ADMINISTRATION PER HIGH FLOW NASAL CANNULA (VAPOTHERM) revised November 2015 revealed "...Procedure: 14. Reassess patient as needed. Care of the Equipment: 1. Always ensure that the system is plugged into a RED outlet ONLY to ensure back up power in the event of a power failure. Documentation on the Vapotherm Log: 1. Document in (named electronic record) on patient's chart on an oxygen therapy powerform..."

Review of "Vapotherm Precision Flow Operating Instruction Manual" revealed "Features: Internal battery backup maintains flow for at least 15 minutes if AC power is cut off. Battery recharges in 2 hours... Section 13 Shut down... Caution: Even a fully charged battery will lose its charge over a period of weeks when the unit is not connected to an AC source..."

Observation during tour on 01/18/2017 at 0939 revealed Vapotherm machines not plugged in while in storage.

Closed record review of Patient #8 revealed a 75 year old male admitted to the facility on 10/11/2016 for diagnoses of Acute Respiratory Failure with obvious signs of pulmonary fibrosis (scarring of the lungs) and asbestosis (chronic lung disease caused by inhaling asbestos) and Sepsis due to pneumonia. Record review revealed a physician order on 10/12/2016 at 1126 for Vapotherm (machine that supplies supplemental oxygen at high flows) to keep sats (oxygen saturation) > (greater than) 86%. Review of nursing progress note on 10/12/2016 at 1916 revealed "Patient remained on cardiac monitor during shift, maintained adequate oxygenation on Vapotherm, free of complaints, all needs met..." Record review revealed no documentation of the patient becoming distressed due to the Vapotherm becoming unplugged.

Interview on 01/19/2017 at 1445 with a Respiratory Therapist #1revealed she was called from a meeting to respond to the Patient #8's room. Interview revealed she found the patient in the bathroom while connected to the Vapotherm. Interview revealed the unit was unplugged and there was no power to the machine. Interview revealed the patient was in distress she placed him on oxygen and helped him to a chair. Interview revealed the patient recovered well from the incident. Interview revealed she does not recall the nursing staff who notified her. Interview revealed she was taught the Vapotherm machines can not be unplugged and will lose the patient settings as well as the machine can not operate. Interview also revealed she did not document the event in the medical record nor document the patient assessment and interventions.

Review of a facility internal investigation revealed interviews of staff were conducted. Review of the investigation revealed "the Vapotherm was unplugged when the patient was taken to the bathroom and he was in distress..."

Interview on 01/19/2017 at 1055 with RN #2 revealed she cared for Patient #8 and does not recall the patient ambulating. Interview revealed most patients on Vapotherm are not ambulatory due to their respiratory status and are too weak to ambulate.

Interview on 01/18/2017 at 1055 with Registered Nurse (RN) #3 revealed nursing does not touch settings on the Vapotherm. Interview revealed she was taught to never unplug the Vapotherm machine due to no battery back up and the machine does not have a memory.

Interview on 01/19/2017 at 0850 with the Respiratory Director revealed the facility switched to new Vapotherm machines in the fall. Interview revealed the previous machines did not have a battery back up and would lose power and settings if the unit became unplugged. Interview revealed the current machines will run for 15 minutes on a charged battery if the unit becomes unplugged.

Interview on 01/19/2017 at 0950 with RN #1 revealed patients who are on Vapotherm do not get out of bed. Interview revealed if the patient is well enough to get up, a bedside commode is brought to bedside for toileting.

Interview on 01/19/2017 at 1430 with a BioMed technician #1 revealed current Vapotherm machines are the same as previous machines. Interview revealed there is no change in the way the older machines and new machines function. Interview revealed the machines can run up to 15 minutes on battery back up. Interview revealed patient care equipment with a battery should be plugged in during storage to maintain battery function. Interview revealed the facility has not had any mechanical issues the with Vapotherm machines. Interview revealed only maintenance requested on the machines were repairing broken doors.

Review of education material presented to staff on 01/19/2017 revealed "Vapotherm Huddle: Please note the following when caring for a patient with Vapotherm: 1) The power cord for the Vapotherm System must be plugged in order for it to work..." Review of material does not mention the battery for the Vapotherm in the event it needs to be unplugged.

NC00122974