Bringing transparency to federal inspections
Tag No.: A0405
31007
31597
REMAINS CITED
Based on medical record review and interview, the hospital failed to ensure drugs were administered per physician orders for three (Patient #5, #8 and #11) of 13 medical records reviewed. This had the potential to affect all 106 of the facility's patients.
Findings include:
1. The medical record review for Patient #5 revealed an admission date of 5/5/14 with a diagnosis of pneumonia. Inhalation treatments were ordered with the medications Albuterol and Ipratropium 2.5 milligrams - 0.5 milligrams /3 milliliters four times per day on 5/5/14 at 11:00 PM. The medical record revealed Patient #5 did not receive the ordered breathing treatments until 5/6/14 at 12:50 PM.
On 5/9/14 at 1:22 PM, the findings were confirmed with Staff A.
2. The medical record review for Patient #8 revealed an admission date of 5/6/14 with a diagnosis of Chronic Obstructive Pulmonary Disease Exacerbation. Inhalation treatments were ordered with the medications Albuterol and Ipratropium 2.5 milligrams - 0.5 milligrams /3 milliliters every four hours while awake on 5/6/14 at 2:32 PM. A respiratory therapist documented on 5/8/14 at 4:00 PM "Patient not available at this time - in bathroom". The medical record lacked evidence the therapist made any additional attempts to give the ordered every four hour breathing treatment to Patient #8 until 7:00 PM when a treatment was given. On 5/9/14 at 2:00 PM, the findings were confirmed with Staff A.
3. The medical record review for Patient #11 revealed admission to the facility on 5/5/14 with a diagnosis of pneumonia. Inhalation treatments were ordered with medication Ipratropium Bromide 0.5 milligrams/ 2.5 milliliters (Atrovent) every six hours on 5/6/14 at 8:33 AM. The record revealed Patient #11 missed the morning breathing treatment on 5/8/14 scheduled for 6:00 AM. The respiratory therapist documented "therapist in emergency room for cardiac arrest" on 5/8/14 at 7:08 AM.
The findings were confirmed with Staff B on 5/9/14 at 11:36 AM. Staff B reported the emergency room events led to Patient #11 not receiving the 6:00 AM dose of the breathing medication Atrovent on 5/8/14. Staff B reported the facility had two respiratory therapists scheduled on 5/8/14 at 6:00 AM.