HospitalInspections.org

Based on policy review, medical record review, and staff interviews, the hospital nursing staff failed to consistently document oral care for ventilator dependent patients in 5 of 7 sampled records reviewed (Patients #14, #15, #17, #18, and #19).

Findings included:

Review of the hospital policy titled "Medical Record Documentation Dimensions Acute" revised August 2020 revealed " ... I. SCOPE/PURPOSE. The purpose of this policy/procedure is to provide documentation guidelines for the patient medical record. II. POLICY. A. The medical record is an interdisciplinary document that reflects accurate and complete documentation and justifies ...and describes the patient's progress and response to treatments, medications and services ...C. Documentation is legible, complete, authenticated, timed and dated as appropriate. D. Documentation should be completed at the time care is delivered and by the person who is delivering the care ..."

Review of the policy titled "Adult Mechanical Ventilation" revised 12/2020 revealed "1. SCOPE/PURPOSE...This policy provides Respiratory Care Practitioner (RCP) for safe effective management of patients requiring mechanical ventilator support...V. PROCEDURE...C. ET tube assessment-including mouth care and ET tube rotation, will be completed every 4 hours on a day shift and with vent (ventilator) assessments on nights (every 6 hours).

Review of hospital policy titled "Assessment/Reassessment, Addendum D, Oral Care Recommendations, Adult Critical Care Department", revised 04/04/2021 revealed "...H2O2 (hydrogen peroxide) or Peroximent ( Product, clean oral cavity w/15 ml (milliliters) 1.5 % H2O2...Every 4 hrs. (hours) & PRN (as needed)...Bicarbonate Impregnated swabs. Clean oral cavity with swab & antiseptic oral rinse...Every 4 hrs. & PRN..."

Review of the Respiratory Therapy policy titled "Ventilation Management/Liberation, and Airway Pressure Release Ventilation...Protocol Orders-Adult" revised 08/23/2018 revealed "...Respiratory Interventions...Oral care every 4 hours. Coordinate with the nurse.

1. Closed medical record review on 09/24/2021 of Patient #14, a 61-year-old male admitted on 07/08/2021 for Pneumonia due to COVID virus. Record review revealed on 07/16/2021 Patient #14 was intubated at 1706, during a cardiac catherization by Medical Doctor (MD) #6 and was placed on a ventilator (mechanical ventilation). Nursing Flowsheets and Respiratory Ventilator Flowsheets from 07/28/2021 through 08/01/2021 were reviewed for oral care and revealed times no oral care was in the medical record as provided for Patient #14: from 07/28/2021 2000 through 07/29/2021 0400 (8 hours), from 07/30/2021 at 0323 through 1630 (13 hours and 7 minutes), from 07/30/2021 at 1630 through 07/31/2021 at 0830 (16 hours), and from 07/31/2021 at 2022 through 08/01/2021 at 0134 (5 hours and 12 minutes). Record review of the Respiratory Therapist (RT) ancillary note dated 08/01/2021 at 1138 by RT #1 revealed "During routine oral care. It is noted that the patient has maggots in his oral cavity. OETT (oral endotracheal tube) Hollister changed. Aggressive oral care performed... RN (registered nurse) aware." Review of the Final Progress Note dated 08/03/2021 at 1559 by MD #7 revealed Patient #14 had expired at 1452 with a preliminary cause of death "Pneumonia due to COVID-19 virus.

Interview on 09/23/2021 at 1410 with Respiratory Therapist for Patient #14 revealed "I do suction and ventilator checks every 6 hours, and oral care every 4 hours and prn (as needed). Ventilator patients have a bite block that has to be moved every 4 hours to prevent pressure sores in the mouth...." Interview revealed oral care was given every 4 hours, as an RT and Nurse shared responsibility. Interview revealed "When I found maggots in (named) patients' mouth, I documented the findings, and reported to the patient's nurse, I didn't complete an ERL (event report log)." Interview revealed RT #1 had never encountered this event before.

Interview on 09/24/2021 at 1210 with RN #2, who was caring for Patient #14 on 08/01/2021 revealed "...I found them. I did mouth care, at first it appeared to be skin flakes, then one fell on the patient's chest and I saw it moving. I asked a medical student just outside the patient's room to report to the physician. I did mouth care to clear them from the patient's mouth. I handed off to the medical student while I notified RT (named). There was no change in the patient's condition...no sight of insects since...I believe another patient had a fly reported in room 136 the same day, I did not witness a fly at all...I raised to management (named), IP and EVS was reached out to. I don't recall any problems with Patient #14's room 131, or any decline or rapid response that day. I have no knowledge of any flies reported since that day..." Interview revealed that oral care was to be completed and documented every 4 hours and was shared by RT and nursing staff. Interview revealed hospital documentation policy was not followed.

Interview on 09/24/2021 at 1230 with Assistant Nurse Manager, RN #5 revealed "I was made aware by (named) RT about the insects in a patients mouth, I completed the ERL and notified administration on call, EVS, and spoke to the on-call IP nurse, and risk management, patient advocate, and the (named)...If there is a situation the nurse cannot do her ADL's (activities of daily living) or oral care, I assist with that. Ventilator patients get oral care every 2 to 4 hours, we work as a team...CCU has enough staff to do the job..." Interview revealed oral care should be documented when completed. Interview revealed hospital documentation policy was not followed.

Interview on 09/27/2021 at 1250 with RN #6 revealed "...I do remember this patient. My routine was to give oral care when I give meds. I gave his meds and gave him oral care. I do my oral care...So the biggest hurdle is with documentation...the oral care gets done..." Interview revealed that RN #7 did oral care for Patient #14, however it was not always documented.

Interview on 09/28/2021 at 1620 with the Director of Respiratory Therapy revealed "...the expectation for oral care for ventilator dependent patients was every 4 hours on day shift 7A-7P, and twice on nights 7P-7A, with ventilator checks at night every 6 hours." Interview revealed oral care should be documented when given. Interview revealed hospital documentation policy was not followed.

Interview on 09/28/2021 at 1630 with Critical Care Manager, RN #3 revealed that the expectation was oral care to be given per hospital policy. Interview revealed "oral care is shared between nursing and respiratory staff and communicated at the beginning of the shift..." Interview revealed "oral care was to be given to ventilator dependent patients every 4 hours." Interview revealed oral care should be documented when given. Interview revealed hospital documentation policy was not followed.

2. Closed medical record review on 09/24/2021 of Patient #15, an 80-year-old female who arrived on 07/22/2021 at 1531 to the emergency room for chest pain, and altered mental status and was emergently intubated with "acute respiratory failure with hypoxia" and placed on a ventilator. Nursing Flowsheets and Respiratory Ventilator Flowsheets from 08/01/2021 through 08/08/2021 were reviewed for oral care and revealed times no oral care was in the medical record as provided for Patient #15: from 08/02/2021 1200 to 08/02/2021 2000 (8 hours), 08/02/2021 2200 to 08/03/2021 0800 (10 hours), 08/05/2021 0100 to 08/05/2021 at 0740 (6 hours and 40 minutes), 08/06/2021 0600 to 08/06/2021 2000 (14 hours), 08/07/2021 2335 to 08/08/2021 at 0529 (5 hours and 24 minutes). Review revealed 08/08/2021 Patient #15 had an acute cerebral vascular accident (stroke) and family decided to go with comfort care measures. Patient #15 expired on 08/08/2021 at 1905.

Interview on 09/24/2021 at 1230 with Assistant Nurse Manager, RN #5 revealed "...If there was a situation when the nurse could not do her ADL's or oral care, I assist with that to include oral care...Ventilator patients get oral care every 2 to 4 hours, we work as a team...CCU has enough staff to do the job..." Interview revealed oral care should be documented when completed. Interview revealed hospital documentation policy was not followed.

Telephone Interview on 09/27/2021 at 1310 with Critical Care RN #7 on night shift revealed "...I do my oral care then pass my medications...It gets busy...I do forget to chart. I do the best that I can..." Interview revealed that oral care was provided every 4 hours shared between RT and nursing and should be documented when given. Interview revealed that hospital documentation policy was not followed.

Interview on 09/28/2021 at 1620 with the Director of Respiratory Therapy revealed "...the expectation for oral care for ventilator dependent patients was every 4 hours on day shift 7A-7P, and twice on nights 7P-7A, with ventilator checks at night every 6 hours." Interview revealed oral care should be documented when given. Interview revealed hospital documentation policy was not followed.

Interview on 09/28/2021 at 1630 with Critical Care Manager, RN #3 revealed that the expectation was oral care to be given per hospital policy. Interview revealed "oral care is shared between nursing and respiratory staff and communicated at the beginning of the shift..." Interview revealed "oral care was to be given to ventilator dependent patients every 4 hours." Interview revealed oral care should be documented when given. Interview revealed hospital documentation policy was not followed.

3. Open medical record review on 09/28/2021 of Patient #17, a 61-year-old female patient who was admitted on 09/13/2021 with Hypoxia and COVID-19 Pneumonia and was placed on the ventilator. Nursing Flowsheets and Respiratory Ventilator Flowsheets from 09/19/2021 through 09/26/2021 were reviewed for oral care and revealed times no oral care was in the medical record as provided for Patient #17: 09/19/2021 0000 to 09/19/2021 0834 (8 hours and 34 minutes), 09/19/2021 1712 to 09/20/2021 0350 (10 hours and 38 minutes), 09/20/2021 0350 to 09/20/2021 1211 (8 hours and 21 minutes), 09/21/2021 1211 to 09/22/2021 0721 (19 hours and 10 minutes), 09/22/2021 0721 to 09/22/2021 1615 (8 hours and 56 minutes), 09/23/2021 0753 to 09/23/2021 1617 (8 hours and 24 minutes), 09/25/2021 2000 to 09/26/2021 0333 (7 hours and 33 minutes). Patient #17 remains hospitalized due to COVID-19 Pneumonia.

Interview on 09/27/2021 at 1250 with Critical Care RN #6, who cared for Patient #7 on 09/21/2021 day shift revealed "I do oral care when I medicate my patients...due to Covid we are charting outside the patient's room, and sometimes it's hard to get completed, because some one sees you standing there, and they ask you for help..." Interview revealed the expectation for oral care was every 4 hours, and was shared by RT and nursing staff. Interview revealed that oral care should be documented when given.

Interview on 09/24/2021 at 1230 with Assistant Nurse Manager, RN #5 revealed "...If there was a situation when the nurse could not do her ADL's or oral care, I assist with that to include oral care...Ventilator patients get oral care every 2 to 4 hours, we work as a team...CCU has enough staff to do the job..." Interview revealed oral care should be documented when completed. Interview revealed hospital documentation policy was not followed.

Interview on 09/28/2021 at 1620 with the Director of Respiratory Therapy revealed "...the expectation for oral care for ventilator dependent patients was every 4 hours on day shift 7A-7P, and twice on nights 7P-7A, with ventilator checks at night every 6 hours." Interview revealed oral care should be documented when given. Interview revealed hospital documentation policy was not followed.

Interview on 09/28/2021 at 1630 with Critical Care Manager, RN #3 revealed that the expectation was oral care to be given per hospital policy. Interview revealed "oral care is shared between nursing and respiratory staff and communicated at the beginning of the shift..." Interview revealed "oral care was to be given to ventilator dependent patients every 4 hours." Interview revealed oral care should be documented when given. Interview revealed hospital documentation policy was not followed.

4. Open medical record review on 09/28/2021 of Patient #18, revealed a 45-year-old male patient admitted on 08/21/2021 with COVID-19 and altered mental status and was placed on the ventilator. Nursing Flowsheets and Respiratory Ventilator Flowsheets from 09/19/2021 through 09/25/2021 were reviewed for oral care and revealed times no oral care was in the medical record as provided for Patient #18: 09/19/2021 0000 to 09/19/2021 1738 (19 hours and 38 minutes), 09/19/2021 1738 to 09/20/2021 at 0300 (9 hours and 22 minutes). Patient #18 remains hospitalized due to COVID-19 pneumonia.

Interview on 09/24/2021 at 1230 with Assistant Nurse Manager, RN #5 revealed "...If there was a situation when the nurse could not do her ADL's or oral care, I assist with that to include oral care...Ventilator patients get oral care every 2 to 4 hours, we work as a team...CCU has enough staff to do the job..." Interview revealed oral care should be documented when completed. Interview revealed hospital documentation policy was not followed.

Interview on 09/24/2021 at 1210 with RN #2, who was caring for Patient #18 on 09/19/2021 day shift revealed that oral care was to be completed and documented every 4 hours and was shared by RT and nursing staff. Interview revealed hospital documentation policy was not followed.

Interview on 09/28/2021 at 1620 with the Director of Respiratory Therapy revealed "...the expectation for oral care for ventilator dependent patients was every 4 hours on day shift 7A-7P, and twice on nights 7P-7A, with ventilator checks at night every 6 hours." Interview revealed oral care should be documented when given. Interview revealed hospital documentation policy was not followed.

Interview on 09/28/2021 at 1630 with Critical Care Manager, RN #3 revealed that the expectation was oral care to be given per hospital policy. Interview revealed "oral care is shared between nursing and respiratory staff and communicated at the beginning of the shift..." Interview revealed "oral care was to be given to ventilator dependent patients every 4 hours." Interview revealed oral care should be documented when given. Interview revealed hospital documentation policy was not followed.

5. Closed medical record review on 09/24/2021 of Patient #19, a 72-year-old male who was admitted on 08/14/202 for acute respiratory failure and a history of COVID-19. Record review revealed Patient #19 was placed on a ventilator on 08/21/2021 after no respiratory improvement. Nursing Flowsheets and Respiratory Ventilator Flowsheets from 08/21/2021 through 08/27/2021 were reviewed for oral care and revealed times no oral care was in the medical record as provided for Patient #19: from 08/22/2021 0849 to 08/22/2021 1452 (6 hours and 3 minutes), 08/23/2021 1530 to 08/24/2021 0102 (9 hours and 32 minutes), 08/24/2021 0102 to 8/24/2021 1000 (8 hours and 58 minutes), 08/24/2021 1000 to 08/24/2021 1935 (9 hours and 35 minutes) 08/24/2021 1935 to 08/25/2021 0300 (7 hours and 25 minutes), 08/25/2021 0518 to 08/25/2021 2003 (14 hours and 45 minutes), 08/25/2021 2030 to 08/26/2021 0321 (6 hours and 51 minutes), 08/26/2021 1232 to408/26/2021 2030 (7 hours and 58 minutes), 08/27/2021 0030 to 08/27/2021 0900 (8 hours and 30 minutes). Review revealed Patient #19 expired on 08/31/2021 at 1634 due to COVID-19.

Interview on 09/24/2021 at 1230 with Assistant Nurse Manager, RN #5 revealed "...If there was a situation when the nurse could not do her ADL's or oral care, I assist with that to include oral care...Ventilator patients get oral care every 2 to 4 hours, we work as a team...CCU has enough staff to do the job..." Interview revealed oral care should be documented when completed. Interview revealed hospital documentation policy was not followed.

Interview on 09/27/2021 at 1440 revealed a Critical Care RN #8, working day shift revealed "...Oral care is given an average of every 4 hours. Although we are well supported, I feel overwhelmed, I do not always feel I can do my job with continuity of care. I always make sure my patients are safe..." Interview revealed oral care should be given and documented every 4 hours when given. Interview revealed hospital documentation policy was not followed.

Interview on 09/28/2021 at 1620 with the Director of Respiratory Therapy revealed "...the expectation for oral care for ventilator dependent patients was every 4 hours on day shift 7A-7P, and twice on nights 7P-7A, with ventilator checks at night every 6 hours." Interview revealed oral care should be documented when given. Interview revealed hospital documentation policy was not followed.

Interview on 09/28/2021 at 1630 with Critical Care Manager, RN #3 revealed that the expectation was oral care to be given per hospital policy. Interview revealed "oral care is shared between nursing and respiratory staff and communicated at the beginning of the shift..." Interview revealed "oral care was to be given to ventilator dependent patients every 4 hours." Interview revealed oral care should be documented when given. Interview revealed hospital documentation policy was not followed.

NC00180575, NC00181206