HospitalInspections.org

Based on review of hospital policies, medical records and staff interviews, respiratory therapy staff failed to ensure scheduled medications were administered according to provider orders and hospital policies for 2 of 2 sampled medical records for patients receiving respiratory medications (Patient #27, Patient #14).

The findings include:

Review on 05/01/2025 of hospital policy "Medication Administration," effective 03/2022 and last revised on 03/2025 with no changes, revealed, "... B. ... The therapist will verify the computerized order, dosage, frequency, and route of administration. ... Schedule for Medication Administration ... Q6 (every 6 hours) = (equals) 0400, 1000, 1600, 2200 ..."

Review on 05/01/2025 of hospital policy "Timely Administration of Scheduled Medications," effective 03/2020 and last revised on 08/2023 with no changes, revealed, "... 2. ... the time schedule allowed when administering non-time critical scheduled medications ... Medications prescribed more frequently than daily, but no more frequently than every 4 hours [:] Within 1 hour- Administer within 1 hour before or after the scheduled time ..."

1. Open medical record review on 05/01/2025 for Patient #27 (Pt) revealed a 55-year-old male that arrived in the Emergency Department (ED) on 04/29/2025 at 1517 with a complaint of shortness of breath. Pt #27 was admitted to the hospital on 04/29/2025 at 2253 for chronic obstructive pulmonary disease (COPD) exacerbation (a sudden and severe worsening of respiratory symptoms in patients with COPD). Review revealed a hospitalist provider order on 04/29/2025 at 2324 for ipratropium-albuterol (a respiratory medication that treats COPD by opening the airway and reducing inflammation) 3 ml (milliliters) to be given by nebulization (conversion of liquid medication to a fine mist for inhalation) every 6 hours by respiratory therapy. Review of the Medication Administration Record (MAR) revealed ipratropium-albuterol was scheduled to be administered at 0400, 1000, 1600, and 2200. Review of the MAR on 04/30/2025 revealed scheduled ipratropium-albuterol was administered at 0034, 0340 (3 hours and 6 minutes after the last dose) and at 0853. At 1000, the scheduled dose of ipratropium-albuterol was cancelled. The MAR revealed ipratropium-albuterol was not given at 1528 with a comment stating the patient was not available. The next dose of ipratropium-albuterol was administered at 1941.

Interview on 05/01/2025 at 0942 with Supervisor #1 revealed respiratory therapists should administer scheduled medications within 1 hour of the scheduled dose, up to 1 hour before or after the scheduled dose time. Interview revealed any doses of ipratropium-albuterol that were administered PRN (as needed) should have been documented as a PRN dose.

Interview on 05/01/2025 at 1657 with Director #2 revealed respiratory medications should be given according to the "Medication Administration" policy and the "Timely Administration of Scheduled Medications" policy. Interview revealed medications given outside of the policy parameters were considered medication errors.

2. Closed medical record review on 04/29/2025 for Patient #14 (Pt) revealed a 75-year-old male that arrived in the ED on 08/31/2022 at 2047 with a complaint of shortness of breath and a history of COPD. Review of the ED Timeline revealed a decision to admit Pt #14 to inpatient on 09/01/2022 at 0245. Review revealed a hospitalist provider order on 09/01/2022 at 0332 for ipratropium-albuterol 3 ml to be given by nebulization every 6 hours by respiratory therapy. Review of the MAR revealed ipratropium-albuterol was scheduled to be administered at 0400, 1000, 1600, and 2200. Pt #14 was transferred to an inpatient unit at 0404. Review of the MAR on 09/01/2022 revealed scheduled ipratropium-albuterol was administered at 0442 and 0815 (3 hours and 33 minutes after last dose), 1511, and 2039. On 09/02/2022, scheduled ipratropium-albuterol was administered at 0351, 0721 (3 hours and 29 minutes after the last dose), 1625 (9 hours and 4 minutes after the last scheduled dose), and 2048 (4 hours and 23 minutes after the last dose). On 09/03/2022, ipratropium-albuterol was administered at 0405 (7 hours and 17 minutes after the last dose), 0826 (4 hours and 21 minutes after the last dose), 1627 (8 hours and 1 minute after the last dose) and 2015 (3 hours and 48 minutes after the last dose). On 09/04/2022, ipratropium-albuterol was administered at 0328 (7 hours and 13 minutes after the last dose) and 0849. Pt #14 was discharged home on 09/04/2022 at 1529.

Interview on 05/01/2025 at 0942 with Supervisor #1 revealed respiratory therapists should administer scheduled medications within 1 hour of the scheduled dose, up to 1 hour before or after the scheduled dose time. Interview revealed any doses of ipratropium-albuterol that were administered PRN (as needed) should have been documented as a PRN dose.

Interview on 05/01/2025 at 1657 with Director #2 revealed respiratory medications should be given according to the "Medication Administration" policy and the "Timely Administration of Scheduled Medications" policy. Interview revealed medications given outside of the policy parameters were considered medication errors.


NC00204996, NC00193670, NC00222463, NC00193645, NC00195332, NC00205383, NC00188287