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Based on reviews and interviews the facility failed to ensure physician orders were given before patients were intubated, administered ventilator/ airway management care, any change of ventilator (vent) settings, and extubation from the ventilator in 4 (1,2,3, and 4) of 4 patients reviewed.

Refer to Tag A01163

Based on records review and interviews the facility failed to ensure physician orders were given before patients were intubated, administered ventilator/ airway management care, any change of ventilator (vent) settings, and extubation from the ventilator in 3 (1,2, and 4) of 3 patients reviewed.

Patient #1
A review of patient #1's chart revealed that he was placed on a vent on 6/22/23 at 2322 (11:22 pm). The Respiratory Therapist (RT ) had written an order at 2320 (11:20 pm) for "Intubation, electronically signed by: ____ (Staff # 20) RRT on 06/22/23 2322 (11:22 pm). Status: Completed Ordering user: ____ (Staff #20), RRT 06/22/23 2322 Frequency: Once 06/22/23 2320." The ordering provider was listed as RN Staff # 9. There was no signature noted by the provider or any physician to intubate the patient.


A review of the physician order revealed patient #1 was ordered ventilation settings by the RT staff # 21 Certified Respiratory Therapist (CRT) on 06/24/23 at 0417. There were no signed physician orders found.

According to the https://www.ncbi.nlm.nih.gov/ revealed:
"Intubation- Intubation means putting a breathing tube through the mouth and into the airway. The breathing tube connects to the ventilator. A ventilator is a medical device that gives oxygen through a breathing tube. It is also known as a respirator or breathing machine
Extubation- Extubation is removing an endotracheal tube (ETT), which is the last step in liberating a patient from the mechanical ventilator."

Review of policy and procedure, "Title: Mechanical Ventilator Initiation and Management for the Medical Patient-RC- Policy Number: 70447.3" stated,
" Policy:
1) Ventilator initiation:
a) Mechanical ventilation will be initiated and managed by the Respiratory Therapist only with a physician's order (Order must contain ventilator settings).
b) Mode- medical patients will initially be ventilated with the assist control mode, unless otherwise ordered by a physician.
c) Tidal Volume- 6-8 ml/kg/IBW.
d) Rate- 18-24 breaths/min.
e) Dead Space- Use dead space between the ETT and HME only if necessary for excess secretions.
f) PEEP- in effort to decrease VAEs initial PEEP will be~ 6 cmH2O.
g) Flow- the use of "AutoFlow," "PRVC" or "APVcmv" will be employed unless otherwise directed by a physician.
h) Inspiratory time- 0.6-1.0 second to achieve desired I:E ratio with consideration of disease process. Normal starting I: E ratio will be 1: 2 - 1:3.
i) FiO2- FiO2 will be titrated to the lowest concentration to maintain SpO2 ~ 92%.
j) Once the patient has been placed on ventilator support, obtain an ABG to confirm adequacy of settings. Wait at least 10 minutes with patient stable and on consistent settings before getting ABG sample.
2) Ventilator management:
a) The physician may choose to order an alternative mode. If an alternative mode of ventilation is ordered, see policy corresponding to that specific mode or follow the physician's orders.
6.) d). Ensure there is an order in the patients chart from the physician for intubation and, if necessary an order for reposition of the ETT.
3.) d.) Ventilator checks will be documented on the ventilator flow sheet every three hours by the respiratory therapist."

Patient #2
A review of patient # 2's chart revealed he was placed on a vent on 7/21/23. A verbal order was found written by staff # 18 RT on 7/21/23 at 1431 (2:31 pm). The order stated, "per RT protocol." There was no physician's signature approving this order for vent care.

The facility was unable to produce a protocol. There were no further physician orders for ventilator care, settings, or airway management. Staff #8 confirmed these findings.

A review of patient #2's RT notes revealed on 7/21/23 at 12:55 pm the RT had documented Fi02 at 100%, BPM of 12, PEEP of 6, and TV of 600. There was no order for these settings.

1340- the RT had documented a change in the vent settings to decrease in the TV to 550.

An interview with Staff # 4 and Staff # 19 on 7/25/23 at 10:15 am confirmed that there was no RT protocol. Staff #4 stated that there was a protocol in 2020 but the facility decided to have no protocols and that all changes for respiratory care would require a physician order. Staff #4 stated that the computer system still allowed for the option but there was no protocol. Staff # 19 confirmed that there had been no protocol in effect for two years and he was aware the RT staff were still writing orders that referred to a protocol. Staff # 19 stated that he had informed RT staff to stop writing orders for protocols but had no staff discipline in the employee files. Staff #19 confirmed that the RTs were performing ventilator care and changing settings without a physician's order.

An interview was conducted with Staff # 1 concerning the orders and protocols for vent care on 7/25/23 at 11:00 am. Staff # 1 stated that the medical director was aware of the RT's putting in orders for protocol and that the computer system allowed the staff to document per protocol even though there were no protocols. Staff #1 stated that in February of 2023 the medical director was planning to take the issue to medical staff, but the medical director resigned, and the issue was not carried any further. Staff #1 was able to provide information from Quality that the issue had been identified but had not been resolved. There was no current plan to work through Quality to address the issue.

Patient #4
A review of patient # 4's chart revealed he was placed on the vent 7/18/23 at 10:17 am. The patient was extubated at 1500 (3:00 pm) by staff # 14 RT, with no physician order.