HospitalInspections.org

Based on documentation review the Hospital failed to ensure respiratory medications were administered as ordered in one of one applicable record reviewed:

Findings include:

Physician orders, dated 2/13/10 indicated albuterol nebulizer (inhalant medications utilized in a devise which produces a fine spray) was ordered every six hours and every three hours if needed. Bi-level Continuous Positive Airway Pressure (BiPAP) (a type of intermittent mechanical ventilation which augments patients ventilation by supplying pressurized air through a mask used in conjunction with oxygen therapy) was ordered with 5 liters (L) of oxygen via nasal cannula from 10:00 PM to 6:00 AM daily and as needed during the day time for excessive somnolence. The admission orders also included Symbicort (inhaled corticosteroid to reduce inflammation in the lungs and keep airways open) 2 puffs twice a day every day and Spiriva once a day (oral inhaled medication for the treatment of breathing problems, used to prevent wheezing).

Review of 2/13/10 and 2/14/10 respiratory care documentation indicated Patient #1 was not placed on BiPAP as ordered at 10:00 PM.

Review of Patient #1's MAR's, dated 2/14/109 indicated Patient #1 was to receive the albuterol nebulizer treatments at 9:00 AM, 3:00 PM and 9:00 PM. Documentation indicated albuterol was administered at 9:16 AM and 1:25 PM. There was no documentation by either respiratory therapy or nursing to indicate why Patient #1 did not received the nebulizer treatments at 3:00 PM and 9:00 PM as ordered or why treatment was administered at 12:25 PM.

Review of Patient #1's MAR dated 2/15/10 indicated Patient #1 was to received the albuterol treatments at 9:00 AM and 3:00 PM. Documentation indicated Patient #1 received the treatments at 11:04 AM and 3:02 PM without documentation of further assessment.