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Based on review of facility documentation, review of the facility policy and interviews, the facility failed to ensure that quality care was provided by the contracted dialysis service. The findings include the following:

a. On 10/05/10 at 10:15 AM the surveyor observed that the test strips utilized to monitor water were not dated upon opening in accordance with the dialysis policy.

b. On 10/5/10, a dialysis nurse was observed to test water for chlorine/chloramines. The nurse was observed to expose the test strip to the sampled water for approximately five (5) seconds although review of the manufactures directions directed the sample be exposed for thirty seconds (30) seconds. Subsequent to this observation the facility provided the department with an immediate action plan that included all staff were reeducated in the proper testing procedures.

c. Review of the documentation for maintenance for six dialysis machines and six portable reverse osmosis units on 10/5/10, inclusive of all water and machine culture testing, identified that testing documentation for specific machines failed to be precise, rendering an inability to understand what test was done on what machine. During interview on 10/6/10, the Facility Administrator (FA) stated that the hospital dialysis unit had replaced three new RO's in September 2009 and that although the unit utilized serial numbers for recognition of each machine identity, that identity was not conveyed throughout the testing documentation.

d. Review of water testing documentation for July, August and September 2010 reflected that the Facility Administrator and Medical Director failed to sign off recognition of the water values per facility policy. During interview on 10/6/10, the Facility Administrator stated that secondary to conflicted meeting times she was unable to meet with the Medical Director to review and sign off testing documentation for the hospital unit during the above referenced months.

e. Review of Patient #70's medical record on 10/5/10, identified that the patient, known to receive outpatient (chronic) hemodialysis, had fractured the right hip and required surgery on 10/4/10. Review of physician's orders (MD #5) identified a telephone order dated 10/4/10 at 8:00 AM to RN #4 (dialysis nurse) directing a hemodialysis treatment using the "chronic orders except change the bath to 2K 2CA and hemodialysis time to 2 hours". A second order, which failed to be dated and timed, directed the patient to have no heparin and no sodium modeling. During interview on 10/5/10, RN #5 stated she initiated the patient's treatment at approximately 8:30 AM according to the physician's order and that MD #5 evaluated the patient at approximately 9:30 AM. MD #5 directed the heparin to be stopped, which occurred. Physician #5 failed to direct complete acute hemodialysis orders (rather than chronic) at the start of hemodialysis treatment and failed to date and time further orders for hemodialysis treatment on 10/4/10.

f. Review of Patient #70's hemodialysis record dated 10/4/10, reflected a dialysis bath of 3K 2 CA, rather than the 2K 2 CA ordered by MD #5. Further, the record reflected that the patient received heparin 1800 units as a loading dose and 600 units as maintenance during treatment, rather than the heparin free treatment as ordered. During interview on 10/5/10, RN #4 stated that Patient #70 did receive the 2K bath as ordered and that she "wrote over" the "3" with a "2", and did not clarify the entry elsewhere in the record. RN #4 stated that MD #5 saw the patient approximately one hour into the treatment and ordered the heparin to be stopped. Although she stopped the heparin, RN #4 stated she failed to document this in the treatment record.

g. Review of the hemodialysis treatment records dated 10/4/10, for Patient #69 and #70, reflected that the nurse failed to initiate pre and post treatment weights secondary to broken equipment. Review of the dialysis policy for patient assessment identified that the pre and post weight of the dialysis patient contributed to the evaluation of the patient's response to treatment.

Based on review of clinical records, review of facility policies, review of facility documentation, and interviews, the facility failed to provided documentation to reflect that the least restrictive restraint device was utilized and/or utilized for the least amount of time for three of four patients, Patients #38, #66, and #67, who had diagnoses of dementia and identified to be at risk to fall. The findings include:

a. Patient #38 was admitted to the facility's Behavioral Health Unit on 9/22/10 with diagnoses that included alcohol related dementia/psychosis and a history of Alzheimer's disease. A fall risk assessment dated 9/22/10 identified that Patient #38 was at risk to fall. Interventions to reduce the patient's risk to fall included to keep the bed in low position and to instruct the patient on use of the call light. Review of nursing notes dated 9/22/10 to 9/28/10 identified that due to Patient #38's cognitive deficits, the patient needed frequent explanations and reinforcement of safety interventions including use of the call bell. The documentation identified that Patient #38 was at high risk to fall and was attempting to walk unassisted. Physician orders dated 9/23/10 at 7:55 PM directed the use of a Posey vest (jacket restraint) for safety for twenty four hours. The documentation failed to identify that a less restrictive device was attempted prior to use of a Posey vest.

b. Review of the nursing assessment dated 9/23/10 at 11:55 PM identified that Patient #38 was calm though restless. The clinical record lacked documentation to reflect that an attempt to release the Posey vest or to utilize a less restrictive device was made. The nursing assessment dated 9/24/10 at 1:55 AM through 9:55 AM identified that Patient #38 was sleeping though was awakened for vital signs. Although the documentation identified no further issues with attempts by Patient #38 to ambulate unassisted as described as the reason for the restraint, a second physician order was written at 9:00 AM on 9/24/10 to continue use of the Posey vest for an additional twenty four hours. The clinical record lacked documentation to reflect that Patient #38's Posey vest was removed, that a trial release was attempted, and or that the use of a less restrictive device was attempted. The restraint was not discontinued until 11:00 AM on 9/24/10.

c. A physician progress note dated 9/24/10 at 9:30 PM identified that Patient #38 was observed to slip off a chair onto his/her buttocks earlier in the evening. The documentation identified that the event was witnessed by facility staff, that there had been no apparent injury, but that based on Patient #38's continued unsteadiness on his/her feet and difficulty following direction due to his/her cognitive status, a Posey vest was reordered for another twenty four hour period. The clinical record lacked documentation to reflect that a less restrictive device was attempted and/or considered prior to use of a Posey vest. Review of the restraint safety monitoring records dated 9/25/10 from 2:47 AM on 9/25/10 through 8:35 AM identified that Patient #38 remained calm and/or was sleeping without the benefit of having the Posey vest removed and/or the attempt to utilize a less restrictive device.

d. Patient #66 arrived in the Emergency Department (ED) on 9/3/10 from a skilled nursing facility with symptoms of dementia and aggressive behavior and was assessed in the ED to be at risk to fall. The documentation identified that Patient #66 became combative in the ED and that a physician order for a Posey vest was obtained at 8:30 AM on 9/3/10. The clinical record lacked documentation to reflect that a less restrictive device was attempted and/or considered prior to use of a Posey vest.

e. Patient #67 arrived in the Emergency Department (ED) on 9/1/10 from a skilled nursing facility with diagnoses that included dementia and behavioral changes and was assessed in the ED to be at risk to fall. The documentation identified that Patient #67 became combative in the ED, was striking out at staff, and that a Posey vest was applied. Patient #67 was subsequently admitted to the facility's Behavioral Health Unit on 9/1/10. A fall risk assessment dated 9/1/10 identified that Patient #67 was at risk to fall. Review of a nursing note dated 9/1/10 at 10:30 PM identified that Patient #67 remained confused and was intermittently agitated, was kicking and screaming, and that the Posey vest was maintained throughout the evening shift. Review of the nursing notes dated 9/2/10 from 1:48 AM through 9:10 AM identified that Patient #67 was sleeping and/or calm when awake. The clinical record lacked documentation to reflect that a trial release of the Posey vest was attempted until 9:10 AM and/or that a less restrictive device was attempted and/or considered.

Interview with the Director of the Behavioral Health Unit on 10/6/10 at 1:30 PM identified that although the unit did not utilize Posey vest restraints based on age, behaviors that could lead to use of a Posey vest restraint on the Behavioral Health Unit included the inability of a patient to follow directions due to his/her cognitive status, the inability to utilize the call bell, and physical impairments that might place a patient at high risk to fall. Review of the facility's Restraint and Seclusion policy directed that the type of restraint used must be the least restrictive intervention that will be effective to protect the patient, a staff member, or others from harm. The policy directed that a restraint may be imposed to ensure the immediate physical safety of the patient and must be discontinued at the earliest possible time The policy directed that a risk of falls was not necessarily a reason for restraining a patient but that a history of falling, a medical condition, or symptom that indicated a need for protective intervention may justify the use of a restraint to promote healing. Review of the facility's Fall Prevention and Safety Assessment and Management policy directed staff to manage patients at risk to fall through assessment and the least restrictive therapeutic/preventive interventions.

Based on review of the clinical record, review of hospital policy and interviews with hospital personnel for one patient undergoing a cardiac catheterization, documentation and interviews failed to reflect a complete medical record. The findings include:

Patient #57 was admitted to the hospital on 9/29/10 and underwent a cardiac catheterization with contrast on 10/5/10. Review of the Assessment and Treatment of Contrast Related Adverse Reactions in the Cath Lab Policy identified that the patient would be assessed before the administration of contrast media using the Intravenous Contrast Checklist for previous reactions. Review of the clinical record identified that the Department of Cardiology Intravenous Contrast Checklist was not completed prior to the procedure for Patient #57.

Based on observation, review of hospital policy, review of hospital documentation and interviews with hospital personnel, documentation and interviews failed to reflect that the hospital medication dispensing policy was followed. The findings include:

On 10/4/10, an observation of the Pyxis machine in the ED Medication Room identified that a medication discrepancy existed. Review of the Automated Dispensing System ADM- Pyxis Policy indicated that correcting the inventory count for any medication would create a discrepancy, which would be researched and resolved. Additionally, for a controlled substance medication discrepancy that could not be resolved at the time that it occurred, an Occurrence Report would be submitted to the Director of Pharmacy and would be reported to the Department of Consumer Protection. Review of the Pyxis MedStation System ED Station Undocumented Discrepancies List noted that the discrepancy for Ativan 2 mg Injection located in the 4-A drawer was unresolved since 9/18/10. Documentation and interview with the RN #5 failed to reflect that that the medication dispensing policy was followed.

1. Based on review of facility policies, observations, and interview, the facility failed to ensure that medications were stored securely from access by unlicensed personnel. The findings include:

a. During a tour of the labor and delivery unit on 10/6/10 at 1:35 PM, four vaginal delivery case carts were observed stored in the clean utility room secured by a keypad lock. The case carts had unlocked top drawers that contained multiple medications including Lidocaine 2%, Naloxone injectable, Oxytocin, and prefilled syringes of Epinephrine. The clean utility room was also the storage area for the unit's blanket warmer. Interview with the Assistant Director of Nursing at the time of the observation identified that unlicensed personnel had keypad access to the room in order to access the blanket warmer. Review of facility policy directed that medications be stored in a secure location at all times.

Based on observation during tour of the Outpatient Endoscopy Unit and interview with hospital personnel, the hospital failed to ensure that outdated medication was discarded. The findings include:

a. During tour of procedure rooms on 10/6/10, multiple canisters of " Hurricane " (benzocaine anesthetic) were found to have expired in 9/10. During interview on 10/6/10, the Manager of the unit stated that nursing staff review all medications for outdates on a monthly basis.


b. Additionally, a vial of Flumazenil was found to be opened and undated. During interview on 10/6/10, the Manager of the unit stated that all vials should be dated when opened and discarded after 30 days or manufacturer ' s expiration date, whichever comes first.

c. During tour of the Reed OR supply room on 10/4/10, identified blood tubes outdated in 9/10, which were removed by the Director of Surgical Services who stated that the supply of blood tubes fell to the Anesthesia Department. She stated that the tubes should have been removed at the end of the month.

Based on review of facility policy, observations, and interviews, the facility failed to maintain a safe and sanitary environment within the dietary department. The findings include:

During a tour of the dietary department on 10/6/10 from 11:05 AM to 12:00 PM, the following observations were made:

a. Tray line staff were observed to be setting up patient trays without the use of gloves. The Dietary Aide who was responsible for pulling clean plates from the rack for the serving of meats, vegetables, and potatoes, was observed to be holding a stack of napkins at the edge of each plate in order to keep his/her hands from touching the actual plate. However, observation of the practice identified that the Dietary Aide used his/her opposite hand to steady the removed stack of plates and that his/her hand made multiple contacts with the opposite plate edge as he/she placed the plates onto the counter. Subsequent to surveyor inquiry, the Dietary Aide was observed to use a glove to handle the plates. Interview with the Chief Dietician at the time of the observation identified that facility policy directed that a "no bare hands" policy would be followed directing that no bare hands would touch the food surface or come in direct contact with the food.

b. At 11:40 AM on 10/6/10, a large dumpster like rolling cart was observed to be overflowing with cardboard boxes, some of which had fallen onto the chef's preparation area and onto the floor. Interview with the Chief Dietician at the time of the observation identified that one of the porters was assigned to empty the trash regularly but thought that he/she had gone for lunch. Two uncovered trash cans filled with various types of trash including food substances were observed in the walkway leading to the dish room and opposite the cook's preparation area. Two food delivery carts with multiple trays of half eaten foods and paper goods were observed to be stored near the trash cans. Review of facility documentation of assigned duties of the porter identified that trash in the kitchen area be emptied at 10:30 AM and again at 3:00 PM. The Chief Dietician could not explain why the porter had not emptied the trash before leaving for lunch but assigned another staff member to remove the trash.

c. Observation in the cold storage refrigerator on 10/6/10 at 11: 45 AM identified a stainless steel bin of ground meat dated 10/2/10. A bin of sliced ham of varying color shades and dated 10/2/10 was also observed. Interview with the Chief Dietician at the time of the observation identified that ground meats were served the same day and that any unused ground meat was discarded. The Chief Dietician stated that sliced meats were used for two days and discarded at the end of the third day.

d. A large, deep plastic tub containing a bottom layer of a butternut squash and apple mixture was observed to covered only by a baking pan. Interview with the Chief Dietician at the time of the observation identified that baking pans were not an appropriate cover for foods as they do not seal the food.

e. Several spoiled and spotted apples that leaked soft brown liquid into the bottom of the storage container were observed in the produce refrigerator. Interview with the Chief Dietician at the time of the observation identified that checks of the produce refrigerator were to be conducted daily.

f. Several trays of individual jello cups were observed to be stored uncovered on a rack in the dessert refrigerator.

Based on observations and interview, the facility failed to store emergency equipment in a manner that promoted quick and easy access to the equipment in the event of an emergency. The findings include:

1. During a tour of the Pomeroy 8 unit on 10/5/10 at 11:45 AM, two emergency code carts (one for adult patients and one for pediatric patients) and the portable emergency suction machine were observed to be tightly stored side by side in the unit's examining room. The adult code cart was positioned behind the door in a manner that when the door was opened, the cart was behind the door. The pediatric code cart was located next to the adult cart and was observed to have several pieces of equipment including intravenous (IV) poles stored in front of it. The portable suction machine was stored in the right corner of the room on a rolling cart but had been stored behind a computer that had been placed on a rolling stand. In an attempt to access the emergency equipment during the observation, multiple moves of other equipment were necessary to get the equipment in a position to be removed from the room. Interview with the Director of the Acute Care Behavioral Health Unit at the time of the observation identified that some of the equipment could be stored elsewhere. Subsequent to surveyor inquiry, the examining room was cleared of excessive equipment allowing for easier access to the stored emergency equipment.




19826

Based on observations and interviews, the hospital failed to ensure that cleaning chemicals were secured. The findings include:
During a tour of the 4th floor, on 10/4/10 at 11:50 A.M., it was identified that the unlocked janitor's closet contained cleaning chemicals stored on the housekeeping cart. Interview with Hospitality Staff #1, on 10/4/10 at 12:00 Noon, identified that he/she had no keys to lock the janitor's closet and he/she left the housekeeping cart unattended for the past thirty-five minutes. Interview with the Hospitality Staff Supervisor, on 10/4/10 at 1:37 P.M., identified that the janitor closets should be locked at all times and the housekeeping carts should be attended to at all times.
In addition, tour of the ninth floor, on 10/4/10 from 2:00 to 3:00 P.M., identified that two unlocked janitor ' s closets that had cleaning chemicals stored. Interview with Hospitality Staff #5, on 10/4/10 at 1:55 P.M., identified that although he/she had a key to lock the janitor ' s closet the closet was unlocked. Interview with Hospitality Staff #6, on 10/4/10 at 2:05 P.M., identified that he/she did not have a key to lock the janitor ' s closet the closet was unlocked.
Subsequently the hospital began an action plan- that included staff education, audit of keys needed and fabrication of keys, revision of facility policy and procedure and random audits of the security of the janitor closets throughout the hospital.

The facility failed to meet the provisions of the Life Safety Code of the National Fire Protection Association (NFPA 101, 2000 edition) that are applicable to Health Care Occupancies. These findings are based on tour and observation of facility, review of policy procedures and maintenance logs and interview of facility personnel.

Please refer to form CMS-2786R Tags K 011, K 018, K025, K029, K033, K046, K072, K074, K075, K076, and K130.

Based on observation during tour of the anesthesia workroom and interview with hospital personnel, the hospital failed to maintain an acceptable level of cleanliness and quality of supplies. The findings include:

a. A tour of the Anesthesia workroom (location of medications and supplies) with the Director of Surgical Services on 10/4/10, identified washed coffee cups, glasses and dishware on a drain board on the counter next to the sink. Fresh fruit in a basket was observed on the counter. During interview on 10/4/10, the Director of Surgical Services identified that the anesthesia staff had a lounge available several doors away in which to keep such supplies and consume food.


b. A tour of the heart room on 10/4/10, identified the medication pyxis, located
within the room, had a screwdriver and miscellaneous screws on top of the machine.
The Director of Surgical Services stated on 10/4/10, that the room was operational
and the tools should not have been left on top of the pyxis.

Based on observation during tour, interview with hospital personnel and/or review of hospital policy, the hospital failed to ensure that infection control practices were exercised by staff within the environment of the Operating Room (OR) and/or Sterile Processing Department and/or hemodialysis. The findings include:

a. During tour of OR #9 on 10/4/10, pieces of silk tape were observed adhered to countertops and adhesive tape was found to be wrapped around the adjustment handle of equipment rendering the equipment unable to be cleaned between cases and/or at the end of the day according to hospital policy that directed all furniture to be " thoroughly scrubbed with disinfectant using effective mechanical friction " .

b. Review of the biological testing of flash sterilizers in the Main OR identified that on 7/11/10, the staff failed to document the time biological tests were placed in the incubator. Review of the hospital policy for sterilization in the OR identified that while the policy failed to direct documentation of the time of incubation initiation, the policy directed staff to read out test results within one hour.

c. During tour of the heart room on 10/4/10, the cardio-pulmonary bypass machine was observed to be set up (tubing and transducers in place) and covered. The set-up lacked a date of expiration. Review of the hospital policy for Cardio-pulmonary Bypass (CPB) Circuit pre-assembly Set-up identified that the CPB should remain in a locked, low traffic area with limited access. The circuit should be dated, initialed and discarded after 7 days.

d. During tour of the semi-restricted area of the OR with the Director of Surgical Services on 10/4/10, identified that a door, (#18), failed to be locked from the stairwell, enabling entrance from the stairwell into the semi-restricted area of the OR corridor. The Director of Surgical Services stated on 10/4/10, that no access to the OR corridor should occur from any stairwell door leading into the semi-restricted zone of the OR.

e. Upon entry into the clean side of the Sterile Processing Center, the surveyor observed that the pass-through window to the decontamination room was propped open with baskets of instruments. The window stayed open while staff answered the telephone before obtaining the instruments and closing the window. The window does not self-close. The Director of Surgical Services stated on 10/5/10 that the window should be open only long enough to pass instruments to the clean side.

f. During tour of the hemodialysis unit on 10/5/10, white vascular clamps were observed to be attached to the handle of the supply cart. Review of the Infection Control Policy for Renal Services identified that all re-usable equipment would be thoroughly disinfected, however, the policy failed to reflect how/where the clamps should be stored following disinfection.






19952

Upon tour of the hospital, review of hospital policies, review of hospital documentation and interviews with hospital personnel, documentation and interviews failed to reflect that the hospital cleaning policies were followed. The findings include:

1. Tour of the Radiology Department identified that the Endovaginal Ultrasound probes were cleaned in the department. Review of the Endovaginal Ultrasound Probe Cleaning Policy identified that that Cidex OPA solution was utilized for cleaning the contaminated equipment and that the transducer would soak in the Cidex OPA solution for a minimum of 12 minutes. Review of the Ultrasound's Cidex Quality Control Log from 7/23/10 through 10/5/10 failed to reflect the time (minimum 12 minutes) the transducer was taken out of the solution on several days (9/2/10, 8/30/10, 8/27/10, 8/23/10, 8/20/10, 8/13/10, 8/9/10, 7/26/10) therfore unable to determine that the probe was soaked the required 12 minutes.

2. Tour of the Cardiopulmonary Department identified that Transesophageal Echocardiogramn (TEE) probes were cleaned in the department. Review of the Transesophageal Echocardiogram Probe Cleaning Policy identified that Cidex OPA solution was utilized for cleaning the contaminated equipment. Review of the TEE cleaning log and the Cidex test strip container failed to reflect the expiration date for the test strips as per manufacturer's guidelines.

Based on review of medical records, review of hospital policy and interview with Anesthesia Personnel, the hospital failed to ensure that the total amount of a medication administered, intraoperatively, was recorded for two patients (Pts #47 K). The findings include:

a. Patient #47 underwent bilateral total knee replacement on 10/4/10. Review of the Anesthesia Record identified that the patient received the medication Propofol beginning at approximately 7:45 AM until approximately 10:10 AM. The Certified Registered Nurse Anesthetist (CRNA) attending the patient failed to record the total amount of medication administered over the course of surgery.
b. Patient #75 underwent a right total hip replacement on 10/4/10. Review of the Anesthesia Record reflected that the patient received Propofol intravenously however, the CRNA failed to document the total amount of medication administered. During interview on 10/6/10, the covering Anesthesiologist stated during interview that the total amount of medication, including that medication administered via a pump, should be documented on the Anesthesia Record.

Based on review of the clinical record, review of hospital policy and interviews with hospital personnel for one patient who received oxygen, documentation and interviews failed to reflect that the hospital oxygen therapy protocol was followed. The findings include:


1. Patient #34 was admitted to the Emergency Department (ED) on 9/29/10 at 1:11 AM with bronchiolitis. Review of the admission vital signs identified that the patient's oxygen saturation (O2 Sat) was 90%. Review of the ED Physician Orders directed to administer humidified oxygen, however, failed to reflect parameters for the oxygen (the flowrate or the oxygen delivery system for administration). Review of the clinical record indicated that oxygen humidification was administered to the patient at 15 liters (L)/minute approximately an hour later at 2:04 AM. The patient's oxygen saturation was 98%, but the record failed to reflect the device utilized. Review of the Oxygen Therapy Protocol indicated that the oxygen delivery system device selected would be based on the amount of oxygen needed to maintain an oxygen saturation of > 92% to < 96% unless otherwise specified by the physician and that it would be documented in the Cerner system. Documentation and interview with ED Nursing Director failed to reflect that the hospital protocol was followed.

Based on review of clinical records, interview and review of facility policies and procedures for one of two patients (Patient #48) that required non-invasive ventilation, the facility failed to ensure that the therapist and/or nurse delivered respiratory care and services according to physician orders. The findings include:
Patient #48 was arrived at the hospital Emergency Department (ED) via ambulance, on 9/30/10 at 4:00 P.M., from home after being found unresponsive, was diagnosed with pulmonary edema and was admitted to the hospital. The patient ' s past medical history included asthma, emphysema and heart disease. Review of the clinical record identified while in the ED Patient #48 received non-invasive ventilation and that was discontinued on 10/1/10 at 12:00 Noon. Review of the physician ' s orders, dated 10/2/10 at 8:45 P.M. directed the staff to administer non-invasive ventilation and the order did not include the inspiratory and/or expiratory pressures. Review of the respiratory flowsheet, dated 10/2/10 at 7:50 P.M., identified that the patient was placed on non-invasive ventilation on an inspiratory pressure of 18 and an expiratory pressure of 6. In addition, on 10/3/10 at 2:22 A.M. documentation reflected that the inspiratory pressure was changed to 16, at 6:22 A.M. the inspiratory pressure was changed back to 18 and review of the clinical record did not reflect physician ' s orders and/or documentation of communication between the therapist and the physician. Interview with the Assistant Director of Respiratory, on 10/4/10 at 11:00 A.M., identified that the physician order for non-invasive ventilation should contain the inspiratory and expiratory pressures and/or the therapist should communicate with the physician regarding the required settings. Review of the facility policy and procedure, titled Non-invasive Positive Pressure ventilation or BiPAP, identified that the starting pressures are inspiratory of 12 and expiratory of 6 and/or as ordered by the physician.
b. In addition, review of the nursing flowsheet, dated 10/3/10 at 8:00 A.M., identified that the nursing staff removed the patient from the non-invasive ventilation and placed the patient on oxygen at 5 Liters per minute via nasal cannula and there was no physician order. Interview with the Assistant Director of Respiratory, on 10/4/10 at 11:00 A.M., identified that a physician order is required. Review of the policy and procedure, titled Oxygen Therapy Protocol, identified that a physician order is required for the administration of oxygen.