HospitalInspections.org

Based on medical record review, review of policy and procedure and interviews, respiratory therapy staff failed to document the administration of three Duoneb treatments as ordered by the physician for Patient Identifier (PI) # 1. This deficient practice affected PI # 1, one of ten sampled patients, and had the potential to affect all patients receiving medication/treatment from respiratory therapy.


Findings include:

1. Medical Record Review:

PI # 1 was admitted to the hospital on 5/15/17 for a total hip arthroplasty (hip replacement). PI # 1's post surgical hospitalization has been complicated by atelectasis (Atelectasis may be the result of a blocked airway or of pressure from outside the lung. Almost every patient who has surgery has some atelectasis from anesthesia. Anesthesia changes the regular pattern of breathing and the absorption of gases and pressures, which may combine to cause some degree of collapse of the tiny air sacs (alveoli) in the lungs, www.mayoclinic.org.

On 5/22/17 PI # 1 was admitted to the inpatient rehabilitation unit. A physician's order dated 5/23/17 revealed Aerosol treatment (Atrovent: brand name for Ipratropium and Albuterol) qid (four times per day) x two days (Also referred to as Duoneb. Medication that relaxes muscles in the airways and increases air flow to the lungs to make breathing easier, www.drugs.com).

An order for Aerosol (Atrovent and Albuterol) treatment qid ( 4 times per day) x two days was ordered by the physician for PI # 1 on 5/23/17.

A physician progress note dated 5/23/17 revealed "Continue with Duonebs for another 24 hours."


2. Policy and Procedure Review:

Title: Administration of Drug - Medication Administration Times
Number 13-09...
Policy: ...
1.2. Scheduled dosing times shall be based on a predetermined set of "standard administration times..."

Procedure 2.1. When processing medication orders, the corresponding scheduled time reflects the standard dosing times: ...

QID (four times daily): 0900, 1300, 1700 and 2100...

2.5 Early or Late Administration of Medications

2.5.1. If a scheduled dose of a medication is late (e.g., patient off floor, dose not available, patient refusal, etc.), the dose is given as soon as possible...


3. Interviews

During an interview on 8/16/17 at 15:10, the Respiratory Therapy Director, Employee Identifier (EI) # 1, confirmed an order for Aerosol (Atrovent and Albuterol) treatment qid ( 4 times per day) x two days was ordered by the physician for PI # 1 on 5/23/17. According to PI # 1, the medication prevents bronchospasms
( a sudden constriction of the muscles in the walls of the bronchioles that causes difficulty in breathing which can be very mild to severe, wikipedia.com. PI # 1 explained the the protocol to follow if a patient is not available at the time the medication is ordered to be given by the Respiratory Therapist (RT) as follows: The RT should return to give the treatment/medication and communicate with the patient's nurse.

According to EI # 1 (RT), the patient received five of the eight Aerosol treatments ordered. The RT could not determine the reason the missing doses were not documented as given by the respiratory therapist.


During an interview on 8/17/17 at 10:25, the Quality Manager, EI # 2, confirmed
three doses of Albuterol and Ipratropium scheduled to be administered to PI # 1 as ordered by the physician were not documented /administered on the following dates:

- 5/23/17 at 1500. No rationale was documented by the Respiratory therapist to indicate the reason the medication was not administered. There was no documentation to indicate the medication was given at a later time;

- 5/24/17 at 11:00. The rationale documented was "Patient (PI # 1) in OT (Occupational Therapy) 10:00 - 11:30. There was no documentation to indicate the medication was given at a later time.

- 5/24/17 at 15:00. The rationale documented was "Patient (PI # 1) in pt (physical therapy) 14:20-15:55." There was no documentation to indicate the medication was given at a later time.

Respiratory staff failed to document/administer three doses of Duoneb for PI # 1 and /or give the dose of medication as soon as possible per hospital policy and procedure to PI # 1, a patient with a history of respiratory compromise post surgery.