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ADVENTHEALTH CONNERTON
ORDERS FOR RESPIRATORY SERVICES
Tag No.: A1163
Based on record review, policy review and staff interview it was determined the facility failed to ensure respiratory care treatments were provided as ordered for 2 (#1, #3) of 11 sampled patients and respiratory assessment performed according to facility policy for 1(#4) of 11 sampled patients. This practice does not ensure safe delivery respiratory treatments/assessments to meet the needs of the patients.
Findings include:
1. Patient #1 was admitted to the facility on 3/2/12. Review of physician orders revealed an order for Duoneb inhalation treatments every 4 hours. Review of the medication administration record (MAR) revealed no evidence that the treatment was administered on 3/3/12 at 7 p.m. and 11 p.m., on 3/6/12 at 7 p.m. and 11 p.m. and on 3/7/12 at 3 a.m.
The Chief Nursing Officer (CNO) was present during the record review on 3/8/12 at approximately 1:00 p.m. and confirmed the finding.
2. Patient #3 was admitted to the facility on 2/19/12. Review of physician orders revealed an order for Duoneb inhalation treatments four times per day. Review of the MAR revealed no evidence that the treatment was administered on 3/3 at 9:00 p.m., on 3/5 at 5:00 p.m. and on 3/6/12 at 9:00 p.m.
The CNO was present during the record review on 3/8/12 at approximately 1:30 p.m. and confirmed the findings.
3. Patient #4 was admitted to the facility on 2/28/12. The patient was ventilator dependent at the time of admission. Review of the Respiratory Care Flow Sheets revealed there were no documented assessments of the patient from 7:30 p.m. on 3/5/12 until 6:40 p.m. on 3/6/12, almost twenty four hours.
The facility's policy "Monitoring Ventilator Patients" # RT-8-000, last reviewed 1/10 required that respiratory therapist are to assess each patient on ventilatory support for specific information every 4 hours.
The Director of Quality Improvement confirmed lack of the required monitoring during interview on 3/8/12 at approximately 4:00 p.m. The Respiratory Therapy manager was unable to find the required documentation.