HospitalInspections.org

Based on policy review, medical record review and interview, the facility failed to follow physician orders for 1 of 3 (Patient #1) sampled patients reviewed.

The findings included:

1. Review of the facility's "Medical Order Policy-Hospitals" (revised 2/7/25) revealed, " ...the RN/LPN [Registered Nurse/Licensed Practical Nurse] is primarily responsible for receipt and recording of physician orders and any necessary transferring onto proper forms, requisitions and computer entries ..."

2. Medical record review revealed Patient #1 was admitted to Hospital #1 on 7/11/25 with diagnosis of acute left leg deep venous thromboembolism (blood clot).

Review of a 7/12/2025 physician's order revealed "Continuous Pulse Oximetry" (test used to measure the oxygen level of the blood).
Record review for Patient #1 from 7/12/2025 through discharge on 7/15/2025 revealed no documentation continuous pulse oximetry was initiated as ordered.

In an interview on 8/7/2025 at 10:15 AM, the Senior Director of Quality verified there was no documentation that continuous pulse oximetry was initiated for Patient #1 as ordered. The Director stated they determined the nursing staff didn't realize they had to call the Respiratory Therapy department to inform them of the order.

In an interview on 8/7/2025 at 10:20 AM, Respiratory Therapist (RT) #1 verified they are notified by nursing staff of an order for continuous pulse oximetry. RT #1 stated there should be a note in the medical record from the RT that delivered the continuous pulse oximetry machine to the patient. No note from RT was found in Patient #1's medical record to indicate continuous pulse oximetry was delivered and initiated.