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Tag No.: A0263
Based on a review of clinical records, staff interviews and a review of hospital policies and procedures for six of ten patients reviewed for mechanical ventilation (Patients #1, #20 #22, #24, #27, and #28), the hospital's quality assurance and performance improvement program failed to collect data, measure and track mechanical ventilation orders and settings to ensure safe quality care.
Despite managerial and/or administrative and/or respiratory care services staff having prior knowledge of problems with practitioner orders and settings for mechanical ventilation, the hospital failed to ensure that the problems were brought to and/or monitored on the unit level or the hospital wide QAPI program.
Please refer to A 0273
Tag No.: A0273
Based on a review of clinical records, staff interviews and a review of hospital documentation for six of ten patients reviewed for mechanical ventilation (Patients #1, #20 #22, #24, #27, and #28) the hospital's quality assurance and performance improvement program failed to collect data, measure, and track the provision of mechanical ventilation even though it was identified over a period of time that ventilation settings did not match the physician's order and/or that ventilation settings were changed by respiratory care practitioners without obtaining a physician's order. The finding included:
1. Review of the clinical record identified Patient #1 was admitted to the hospital on 6/12/14 with a diagnosis that included Crohn's disease, and presented to the hospital for an elective lysis of adhesions and a revision of the end to end anastomosis to an isoperistaltic side to side anastomosis. Post-operatively Patient #1 was placed on mechanical ventilation and transferred to the intensive care unit. Physician orders dated 6/13/14 at 10:21 AM directed mechanical ventilation with settings that included 100 percent (%) oxygen, a respiratory rate of 30 breaths/minute (min), and a Positive End Expiratory Pressure (PEEP) of 12. On 6/13/14 at 10:55 AM the respiratory rate was changed by Certified Respiratory Therapist (CRT) #1 from 16 breaths/min to 20 breaths/min and again adjusted at 11:58 AM from 20 breaths/min to 24 breaths/min. At 11:48 AM on 6/13/14 the PEEP was changed by CRT #1 from 5 to 8.
Interview and review of the physician's orders with RN #4 (staff development nurse in the intensive care unit) on 8/14/14 at 1:00 PM identified that the three ventilation changes for Patient #1 were made by the respiratory care practitioner absent a physician's order and/or with a verbal order that as not authenticated by the prescriber. Further interview with RN #4 indicated the ventilator settings on 6/13/14 at 10:55 AM failed to correspond with the physician's orders prior to the adjustments. RN #4 indicated ventilation changes can only be made with a physician's order and CRT #1 should have notified the physician to obtain orders that were necessary for the care of Patient #1.
2. Review of the clinical record identified Patient #20 was admitted to the hospital on 7/29/14 with severe alcohol withdrawal and Wernicke encephalopathy that required intubation for airway protection. Physician's orders dated 7/30/14 at 2:35 PM directed mechanical ventilation with settings that included a respiratory rate of 14 breaths/min, a tidal volume of 500, oxygen administration at 35 % and a PEEP of 5. On 8/2/14 at 9:35 PM the amount of oxygen administered to Patient #20 was changed from 40 % to 35 % by CRT #2.
Interview and review of the clinical record with RN #4 on 8/14/14 at 1:30 PM identified mechanical ventilation settings failed to correspond with the physician's orders. Further interview and review of the clinical record with RN #4 identified oxygen was administered at 40 % without a physician's order from 7/30/14 at 5:43 PM through 8/2/14 at 9:35 PM. RN #4 indicated ventilation changes can only be made with a physician's order and CRT #2 should have notified the physician to obtain orders that were necessary for the care of Patient #1.
3. Review of the clinical record identified Patient #22 was admitted to the hospital on 4/9/14 with pneumonia and acute respiratory failure that required intubation. Physician's orders dated 4/10/14 at 5:27 AM directed mechanical ventilation with settings that included a respiratory rate of 12 breaths/min, a tidal volume of 450, oxygen administration at 40 % and a PEEP of 5. On 4/11/14 at 12:08 PM the respiratory rate was changed by CRT#3 from 14 breaths/min to 12 breaths/min and the amount of oxygen administered to Patient #22 was changed from 50 % to 40 %.
Interview and review of the clinical record with RN #4 on 8/14/14 at 2:00 PM identified mechanical ventilation settings failed to correspond with the physician's orders. Further interview with RN #4 indicated the respiratory care practitioner should have notified the physician to obtain orders for ventilation settings that were necessary for the care of Patient #22.
4. Review of the clinical record identified Patient # 24 was admitted to the hospital on 3/21/14 with complaints of shortness of breath. Patient #24 was intubated in the emergency room and transferred to the intensive care unit. Physician's orders dated 3/21/14 at 12:15 PM directed mechanical ventilation with settings that included a respiratory rate of 20 breaths/min, a tidal volume of 550, oxygen administration of 55% and a PEEP of 5. On 3/21/14 at 2:10 PM the respiratory rate was changed by RRT #1 from 16 breaths/min to 20 breaths/min and at 2:25 PM the tidal volume was changed by RRT #1 from 500 to 550.
Interview with RN #4 on 8/14/14 at 2:35 PM identified mechanical ventilation settings failed to correspond with the physician's orders. Further interview and review of the clinical record with RN #4 indicated the respiratory care practitioner should have notified the physician to obtain orders for ventilation settings that were necessary for the care of Patient #24.
5. Review of the clinical record identified Patient # 27 was admitted to the hospital on 5/11/14 with an altered mental status and was diagnosed with rhabdomyelosis and acute kidney injury. Patient #27 was intubated for airway protection due to uremic encephalopathy. Physician orders dated 5/11/14 at 9:17 PM directed mechanical ventilation with settings that included a respiratory rate of 18 breaths/min, a tidal volume of 500, oxygen administration of 50 % and a PEEP of 5. Review of the clinical record identified on 5/12/14 at 6:47 AM the amount of oxygen administered to Patient #27 was changed by RRT #2 from 100 % to 50 %.
Interview with RN #4 on 8/14/14 at 3:10 PM indicated Patient #27 was maintained on 100 % oxygen for nine and a half hours absent a physician's order. RN #4 identified the physician should have been notified immediately if the patient required addition oxygen so that assessments, interventions and/or treatment could have been implemented by a staff member with prescriptive authority.
6. Review of the clinical record identified Patient #28 was admitted to the hospital on 2/26/14 with a chief complaint of general weakness and was diagnosed with pneumonia. The patient became hypoxic, was transferred to the intensive care unit and required mechanical ventilation. Physician's orders dated 3/2/14 at 11:47 AM directed mechanical ventilation with settings that included a respiratory rate of 12 breaths/min, a tidal volume of 300, oxygen administration of 30 % and a PEEP of 5. On 3/4/14 at 5:27 PM Continuous Positive Airway Pressure (CPAP) was discontinued by RRT #3 and volume control was implemented. The order was placed by RRT #3 and not authenticated by a physician's until 3/5/14 at 8:46 AM.
Interview with RN #4 on 8/14/14 at 4:00 PM identified a physician's order should have been obtained to wean mechanical ventilation.
Interview with RRT #1 and #3 on 8/13/14 indicated at times ventilator changes were made by respiratory practitioner's based on their assessment, without obtaining a physician's order. RRT #3 identified he/she would make changes to ventilation settings and would wait until the physician came into the intensive care unit or until the morning to notify the doctor of the ventilation changes.
Interview with the Director of Respiratory (MD #30) on 8/18/14 at 11:00 AM indicated the hospitalist was the primary source for physician's orders in the intensive care unit.
Interview with Manager #6 on 8/13/14 at 2:20 PM identified that he/she was aware that ventilation setting changes were made by respiratory care practitioners and that the settings did not always correspond to physician orders. Manager #6 identified that he/she did not initiate auditing, collection of data, and/or monitoring of mechanical ventilation orders to ensure compliance with the hospital policies.
Interview with Quality Manager #1 on 8/13/14 at 3:17 PM indicated the quality committee was not aware that orders related to mechanical ventilation in the intensive care unit was a concern therefore, was not monitored by the hospital wide quality assurance program.
The hospital bylaws dated 10/2/13 directed the administration of all treatments required an order by a physician or other individual permitted to submit orders consistent with the bylaws and credentialing process of the hospital.
Interview with Quality Manager #2 on 8/18/14 at 3:40 PM identified individuals that are permitted to submit orders other than physicians are nurse practitioners and physician's assistants, and does not include respiratory practitioners.
The hospital policy entitled Mechanical Ventilation directed that mechanical ventilation orders were obtained from a physician. The policy further directed that ventilation parameters and all changes would be adjusted by the respiratory care practitioner as ordered by the physician and that weaning from mechanical ventilation would be instituted by a physician's order.
Tag No.: A1151
Based on clinical record reviews, staff interviews and a review of the hospital's policies and procedures for six of ten patients reviewed for mechanical ventilation (Patient #1, #20 #22, #24, #27, and #28), the hospital failed to ensure physician's orders were followed and/or that respiratory services were delivered in accordance with the hospital's policies, procedures and within the scope of practice.
Despite managerial and/or administrative and/or respiratory care services staff having prior knowledge of problems with practitioner orders and settings for mechanical ventilation, the hospital failed to ensure that respiratory care services addressed these known problems.
Refer to A 1163
Tag No.: A1163
Based on clinical record reviews, staff interviews and a review of hospital's policies and procedures for six of ten patients reviewed for mechanical ventilation (Patients #1, #20 #22, #24, #27, and #28), the hospital failed to ensure physician's orders were followed and/or respiratory care services were delivered in accordance with the hospitals policies and procedures. The findings included:
1. Review of the clinical record identified Patient #1 was admitted to the hospital on 6/12/14 with a diagnosis that included Crohn's disease, and presented to the hospital for an elective lysis of adhesions and a revision of the end to end anastomosis to an isoperistaltic side to side anastomosis. Post-operatively Patient #1 was placed on mechanical ventilation and transferred to the intensive care unit. Physician orders dated 6/13/14 at 10:21 AM directed mechanical ventilation with settings that included 100 percent (%) oxygen, a respiratory rate of 30 breaths/minute (min), and a Positive End Expiratory Pressure (PEEP) of 12. On 6/13/14 at 10:55 AM the respiratory rate was changed by Certified Respiratory Therapist (CRT) #1 from 16 breaths/min to 20 breaths/min and again adjusted at 11:58 AM from 20 breaths/min to 24 breaths/min. At 11:48 AM on 6/13/14 the PEEP was changed by CRT #1 from 5 to 8.
Interview and review of the physician's orders with RN #4 (staff development nurse in the intensive care unit) on 8/14/14 at 1:00 PM identified that the three ventilation changes for Patient #1 were made by the respiratory care practitioner absent a physician's order and/or with a verbal order that as not authenticated by the prescriber. Further interview with RN #4 indicated the ventilator settings on 6/13/14 at 10:55 AM failed to correspond with the physician's orders prior to the adjustments. RN #4 indicated ventilation changes can only be made with a physician's order and CRT #1 should have notified the physician to obtain orders that were necessary for the care of Patient #1.
2. Review of the clinical record identified Patient #20 was admitted to the hospital on 7/29/14 with severe alcohol withdrawal and Wernicke encephalopathy that required intubation for airway protection. Physician's orders dated 7/30/14 at 2:35 PM directed mechanical ventilation with settings that included a respiratory rate of 14 breaths/min, a tidal volume of 500, oxygen administration at 35 % and a PEEP of 5. On 8/2/14 at 9:35 PM the amount of oxygen administered to Patient #20 was changed from 40 % to 35 % by CRT #2.
Interview and review of the clinical record with RN #4 on 8/14/14 at 1:30 PM identified mechanical ventilation settings failed to correspond with the physician's orders. Further interview and review of the clinical record with RN #4 identified oxygen was administered at 40 % without a physician's order from 7/30/14 at 5:43 PM through 8/2/14 at 9:35 PM. RN #4 indicated ventilation changes can only be made with a physician's order and CRT #2 should have notified the physician to obtain orders that were necessary for the care of Patient #1.
3. Review of the clinical record identified Patient #22 was admitted to the hospital on 4/9/14 with pneumonia and acute respiratory failure that required intubation. Physician's orders dated 4/10/14 at 5:27 AM directed mechanical ventilation with settings that included a respiratory rate of 12 breaths/min, a tidal volume of 450, oxygen administration at 40 % and a PEEP of 5. On 4/11/14 at 12:08 PM the respiratory rate was changed by CRT#3 from 14 breaths/min to 12 breaths/min and the amount of oxygen administered to Patient #22 was changed from 50 % to 40 %.
Interview and review of the clinical record with RN #4 on 8/14/14 at 2:00 PM identified mechanical ventilation settings failed to correspond with the physician's orders. Further interview with RN #4 indicated the respiratory care practitioner should have notified the physician to obtain orders for ventilation settings that were necessary for the care of Patient #22.
4. Review of the clinical record identified Patient # 24 was admitted to the hospital on 3/21/14 with complaints of shortness of breath. Patient #24 was intubated in the emergency room and transferred to the intensive care unit. Physician's orders dated 3/21/14 at 12:15 PM directed mechanical ventilation with settings that included a respiratory rate of 20 breaths/min, a tidal volume of 550, oxygen administration of 55% and a PEEP of 5. On 3/21/14 at 2:10 PM the respiratory rate was changed by RRT #1 from 16 breaths/min to 20 breaths/min and at 2:25 PM the tidal volume was changed by RRT #1 from 500 to 550.
Interview with RN #4 on 8/14/14 at 2:35 PM identified mechanical ventilation settings failed to correspond with the physician's orders. Further interview and review of the clinical record with RN #4 indicated the respiratory care practitioner should have notified the physician to obtain orders for ventilation settings that were necessary for the care of Patient #24.
5. Review of the clinical record identified Patient # 27 was admitted to the hospital on 5/11/14 with an altered mental status and was diagnosed with rhabdomyelosis and acute kidney injury. Patient #27 was intubated for airway protection due to uremic encephalopathy. Physician orders dated 5/11/14 at 9:17 PM directed mechanical ventilation with settings that included a respiratory rate of 18 breaths/min, a tidal volume of 500, oxygen administration of 50 % and a PEEP of 5. Review of the clinical record identified on 5/12/14 at 6:47 AM the amount of oxygen administered to Patient #27 was changed by RRT #2 from 100 % to 50 %.
Interview with RN #4 on 8/14/14 at 3:10 PM indicated Patient #27 was maintained on 100 % oxygen for nine and a half hours absent a physician's order. RN #4 identified the physician should have been notified immediately if the patient required addition oxygen so that assessments, interventions and/or treatment could have been implemented by a staff member with prescriptive authority.
6. Review of the clinical record identified Patient #28 was admitted to the hospital on 2/26/14 with a chief complaint of general weakness and was diagnosed with pneumonia. The patient became hypoxic, was transferred to the intensive care unit and required mechanical ventilation. Physician's orders dated 3/2/14 at 11:47 AM directed mechanical ventilation with settings that included a respiratory rate of 12 breaths/min, a tidal volume of 300, oxygen administration of 30 % and a PEEP of 5. On 3/4/14 at 5:27 PM Continuous Positive Airway Pressure (CPAP) was discontinued by RRT #3 and volume control was implemented. The order was placed by RRT #3 and not authenticated by a physician's until 3/5/14 at 8:46 AM.
Interview with RN #4 on 8/14/14 at 4:00 PM identified an order should have been obtained to wean mechanical ventilation.
Interview with RRT #1 and #3 on 8/13/14 indicated at times ventilator changes were made by respiratory practitioner's based on their assessment, without obtaining a physician's order. RRT #3 identified he/she would make changes to ventilation settings and would wait until the physician came into the intensive care unit or until the morning to notify the doctor of the ventilation changes.
Interview with the Director of Respiratory (MD #30) on 8/18/14 at 11:00 AM indicated the hospitalist was the primary source for physician's orders in the intensive care unit.
Interview with Manager #6 on 8/13/14 at 2:20 PM identified that he/she was aware that ventilation setting changes were made by respiratory care practitioners and that the settings did not always correspond to physician orders.
The hospital bylaws dated 10/2/13 directed the administration of all treatments required an order by a physician or other individual permitted to submit orders consistent with the bylaws and credentialing process of the hospital.
Interview with Quality Manager #2 on 8/18/14 at 3:40 PM identified individuals that are permitted to submit orders other than physicians are nurse practitioners and physician's assistants, and does not include respiratory practitioners.
The hospital policy entitled Mechanical Ventilation directed that mechanical ventilation orders were obtained from a physician. The policy further directed that ventilation parameters and all changes would be adjusted by the respiratory care practitioner as ordered by the physician and that weaning from mechanical ventilation would be instituted by a physician's order.
The hospital policy entitled verbal and telephone orders for respiratory therapy directed in part respiratory care practitioners may accept and write telephone orders in an emergency from a physician for respiratory care services. All orders must be specific as to the respiratory care modality and noted on the physician order section of the record. Each notation must include the date, time, dosage, frequency of the order and ordering physician and the registered respiratory therapist was responsible to enter these orders into the clinical Information system using the order mode "Telephone Order Read Back." Although the policy identified that telephone orders were allowable, the policy failed to identify that verbal orders may be obtained by the respiratory care practitioner.
The job description for Respiratory Care Practitioner's (RCP) l and ll directed that the therapist would prove care according to the established plan of care, including complex treatment, procedures and assessments that required professional judgment and initiative, as well as routine respiratory therapy.
Additionally the RCP would monitor the patient for any variance in the clinical component of the clinical pathway, routinely exercise sound judgment based on policies, procedures and accepted standards of care. The RCP would also collaborate with team members to plan, implement and evaluate interventions on the clinical pathway. The RCP would communicate therapeutic regime, patient outcomes and variances to the case manager in a timely manner. Lastly the RCP would confer regularly with physicians and write verbal and telephone orders.
Subsequent to the survey findings related to ventilation orders and settings on 8/12/14 an immediate plan of correction was obtained that identified the hospital would review and update the respiratory care policies related to mechanical ventilation. Additionally a review of the respiratory therapist's scope of practice with each healthcare provider would be conducted at the start of each working shift. Immediate notification of physician provider groups would be implemented via conversation or email. The education would be ongoing until all RCP's and intensive care nurses completed the requirement. Audits would be conducted for three consecutive months to ensure that mechanical ventilation orders and changes were made only as directed by a physician's order.