HospitalInspections.org

Based on observation, interview and record review the facility failed to ensure the monitoring equipment for a patient ' s oxygenation status was in good working order for 1 (#2) of 5 patients on a pulse oximeter.
Findings:
Review of the record for Patient #2 (room 5103) on 11/09/15, revealed he was admitted on 09/18/15 with ventilator dependent respiratory failure. The care plan identified potential for airway displacement.
During an observation on 11/09/15 at 9:34 AM, The pulse oximeter probe for patient #2 in room 5103 was removed from the patient to test and the alarm did not sound at 9:34 AM, 9:37 AM and 9:40 AM. The Respiratory Therapy Supervisor checked for the connections and stated the pulse oximetry was not alarming. She stated there would be no alarm at the nurse ' s station or at the monitor ' s station. The Respiratory Therapy Supervisor changed the plug from the pulse oximeter monitor to the wall and the alarm again was checked and showed that they worked.
During an observation on 11/10/15 at 10:30 AM, Risk Manager, entered room 5103 (Patient #2) to check the pulse oximeter alarm. The monitor technician did not page overhead to see if someone was in the room. No one was at the nurse ' s station. The Respiratory Therapist called the monitor tech. The monitor tech did not hear the alarm.
During an interview on 11/09/15 at 9:54 AM, Risk Manager, said staff should have called overhead and asked if there was staff in the room. She stated the ventilator alarm was heard at the nurse ' s station.
During an interview on 11/09/15 at 11:45 AM, monitor technician revealed the pulse oximeters are monitored with an alarm that lights up outside the patient door, at the nurse ' s station and near the monitor technician. The respiratory alarm lights up on the intercom box and sounds an alarm.
During an observation on 11/09/15 at 10:35 AM, of a recheck of the pulse oximeter, in room 5103 showed the light not working. The alarm starting sounding at 10:40 AM and was observed from the hall not lighting up outside the door. The charge nurse said the light did not light up at the nurse ' s station.
During an interview on 11/10/15 at 10:50 AM, Risk Manager,stated if the wall outlet is not working the patient should be moved.
On 11/10/15 at 10:51 AM the Respiratory Therapist stated the alarm light outside the door should be lit up. She said she did not understand why she tried 3 pulse oximeter machines and 3 cables and it still was not working. She then left to get another pulse oximeter monitor.
Further observation on 11/09/15 at 10:53 AM, recheck of the pulse oximeter alarm by the Respiratory Therapy Supervisor, revealed no alarm at monitor station and no alarm at the alarm light outside the door.
Further interview on 11/10/15 at 10:56 AM, Respiratory Therapy Supervisor, states she was going to change the pulse oximeter probe, the only thing she had not changed.
Further observation on 11/09/15 at 11:00 AM, Respiratory Therapy Supervisor, rechecked the alarm and it was not working. She pushed the cords further in. The pulse oximeter alarm worked at the alarm light. The audible alarm worked at the monitor station. Tested gain and lighted at monitor tech station and over the door.
During an interview on 11/09/15 at 11:04 AM, Respiratory Therapy Supervisor, revealed the alarms on the pulse oximeters are checked on admission when set up. The check is not documented and the alarms are not rechecked.
During an interview on 11/09/15 at 1:58 PM, Respiratory Therapy Supervisor, revealed the ventilator does not have a way to monitor pulse oximeter. She confirmed the prongs to the pulse oximeter plug were bent. The cable to the finger was not working. It is not routinely changed. The patient had been on continuous monitoring since admission.
Review of the policy and procdure, titled " Pulse Oximeter Monitoring and Oxygen Saturation Maintenance Policy" dated 03/07, shows all patients with an artificial airway or Bipap as a treatment for acute respiratory failure will be monitored on a continuous pulse oximeter. Audible alarms will be set on maximum audio setting. All audible alarms will be addressed by closest clinical staff. Inoperable or defective pulse oximeter monitor or sensors will be taken out of service immediately using defective equipment procedure and a replacement monitor/sensor will be placed in operation and appropriate documentation will be made. Continuous pulse oximetry remains on at all times.