HospitalInspections.org

Based on observation, interview, record review, review of facility's policies and documents, and review of medication package inserts, it was determined the facility failed to provide care in a safe setting for one (1) sampled patient, Patient #1, and four (4) of five (5) unsampled patients, Patient #11, #12, #14, and #15 (refer to A0144).

Patient #1 was admitted to the facility on 05/08/15 with diagnoses which included Stage IV Squamous Cell Cancer of the Lung, Anemia, Hyponatremia, Hyperkalemia, Acute Kidney Injury, Syncope, Hemoptysis, and Dehydration. Patient #1 was ordered an albuterol inhaler two (2) inhalations every four (4) hours as needed for shortness of breath.

On 5/09/15 at 5:17 PM Patient #1 was given by Registered Nurse (RN) #1 an albuterol inhaler to be left at the bedside with sixty (60) inhalations. On 05/10/15 at 9:09 PM, Patient #1 was given a second inhaler by RN #3 who observed the first inhaler had no doses remaining. There was no physician order for the medication to be left at the patient's bedside for self-administration. Also, there were no doses charted on the medication administration record (MAR). There was no assessment that Patient #1 could safely self-administer the inhaler; and there was no specific education given to the patient on the inhaler documented in the nurses notes.

Patient #11, #12, #14, and #15 were unsampled patients that had at least one (1) respiratory inhaler left at the bedside without a physician's order to do so. They also had no teaching on the use of the inhaler documented and no assessment of the patient's ability to self-medicate documented in the medical record.

The failure of the facility to provide a safe environment placed Patient #1, #11, #12, #14, and #15 at risk for side effects from overdosage of albuterol and/or Dulera inhalers. (Refer to A0144)

Based on observation, interview, review of facility's policies and documents, and review of medication package inserts, it was determined the facility failed to ensure medications left at the patient's bedside were ordered to be at the bedside by the physician, monitored for use, verified that the patient had the ability to safely administer them, patient-educated on their use, and/or charted on the medication administration record (MAR) for one (1) of ten (10) sampled patients, Patient #1 and four (4) of five (5) unsampled patients, Patients #11, #12, #14, and #15.

The findings include:

Review of the facility's policy, "Administration and Documentation of Medications," policy ND14-01, review/revision date 01/04/13, revealed medications that were ordered specifically by the licensed independent practitioner to be kept at the bedside would be documented in the PRN (as needed) section of the MAR.

Review of the facility's policy, "Administration of Medications Brought into the Hospital by Patients," policy ND14-04, review/revision date 03/2011, revealed all medications taken at home shall be documented in the patient's medication history, and any administration of the medication shall be recorded on the patient's MAR. The policy further revealed upon receiving an order for self-medication, the pharmacy shall enter all medications involved with the appropriate dosages, etc. which would allow the medication to be on the daily MAR for the nursing staff to record doses the patient had taken. Also, if the patient's supply of personal medication was exhausted, the pharmacy would supply the patient with medication, per physician's order. The pharmacy staff would note in the MAR that the medication was to be self-administered. In addition, the policy also stated nursing would provide the patient with instructions and monitor the self-administration of medications to include verifying that the patient had the ability to safely and compitently administer the medication; instructing and documenting the patient on the name of the medication, method of administration, dose, reason for use, and frequency of administration; and alerting the patient of potential adverse reactions and the importance of reporting any problems to the nurse.

Review of the package insert for the albuterol sulfate inhalation aerosol (ProAir, IVAX Laboratories, Inc., 2005) revealed it was a beta-adrenergic agonist (used to relax airways and make breathing easier) prevention of acute episodes of bronchospasm. The usual dosage was two (2) inhalation repeated every four (4) to six (6) hours, and more frequent administration or a larger number of inhalations was not recommended. Also, the insert stated the expected symptoms with overdosage were seizures, angina, hypertension or hypotension, tachycardia, with rates up to two hundred (200) beats per minute, arrhythmias, nervousness, headache, tremor, dry mouth, palpitation, nausea, dines, fatigue, malaise, insomnia, and hypokalemia. It further revealed cardiac arrest and even death may be associated with abuse of the inhaler.

Review of the package insert for Dulera inhaler (Merck & Co.Inc., 2010, a combination product that contained a corticosteroid to decrease inflammation and a long-acting beta-adrenergic agonist) revealed it was used for treatment of asthma in patient twelve (12) years of age or older. It also revealed Dulera should not be used more often than recommended. It stated clinically significant cardiovascular effects and fatalities had been reported in association with excessive use of inhaled sympathomimetic drugs (mimic the effects of stimulation of the sympathetic nervous system such as tachycardia and hypertension). Also, the insert stated the expected symptoms with overdosage were seizures, angina, hypertension or hypotension, tachycardia, with rates up to two hundred (200) beats per minute, arrhythmias, nervousness, headache, tremor, dry mouth, palpitation, nausea, dines, fatigue, malaise, and insomnia.

Review of the "All Transaction Activity Detail Report", 05/07/15 - 05/12/15, for Patient #1 revealed he/she was charged for an albuterol MDI with sixty (60) inhalations per unit on 05/09/15 at 5:17 PM, and RN #2 removed one from the Pyxis for the patient at this time. Patient #1 was again charged for an albuterol MDI on 05/10/15 at 9:09 PM, and RN #3 removed one from the Pyxis at the same time. Therefore, thirty (30) doses or sixty (60) inhalations were self-administered by Patient #1 in an approximate twenty-eight (28) hour period when the ordered dose would have been seven (7) or fourteen (14) inhalations.

1. Review of Patient #1's medical record revealed he/she was admitted on 05/08/15 to a room on 6 North with diagnoses which included Stage IV Squamous Cell Cancer of the Lung, Anemia, Hyponatremia, Hyperkalemia, Acute Kidney Injury, Syncope, Hemoptysis, and Dehydration. On 05/09/15 at 12:15 PM, Patient #1's physician ordered Albuterol Inhalation Metered Dose Inhaler (MDI) two (2) inhalations every four (4) hours PRN for shortness of breath (SOB); the record also revealed he/she was on this medication at home. Further review revealed the order for the albuterol inhaler did not state Patient #1 could keep this medication at his/her bedside. Review of the MAR revealed this medication was listed as a PRN medication, and there was no documentation on the MAR for 05/09/15 or 05/10/15 that Patient #1 received any doses of the MDI. There was also no documentation that Patient #1 was assessed as to his/her ability to self-medicate or teaching by the nurses about this medication, for instance the dose, frequency, and adverse effects. The record further revealed on 05/11/15 at 1:15 AM Central Monitoring (monitored patients on telemetry) informed Registered Nurse (RN) #1 that Patient #1's heart rate was forty (40) beats per minute (BPM), and upon her entering the patient's room, she found him/her unresponsive and without a pulse. Cardiopulmonary resuscitation (CPR) was initiated and a code called. Patient #1 was intubated at 1:23 AM and a spontaneous pulse returned at 1:33 PM; at 1:55 AM the pulmonary team and the code team transported Patient #1 to the Intensive Care Unit (ICU). Further review revealed at this point his/her heart rate was 189 BPM and he/she was unresponsive with a Glasgow Coma Scale (GCS; a scale from zero (0) to fifteen (15) that measures neurological status; the higher the score, the less deficits the patient has) score of three (3). Further review revealed Patient #1 had the albuterol MDI ordered as on the floor when admitted to the ICU; then on 05/12/15 at 8:10 AM the doses were changed from PRN to scheduled doses every four (4) hours which were administered by respiratory therapy. In addition, the ICU history and physical, dated 05/11/15 at 2:13 AM, revealed the cardiopulmonary arrest was secondary to an airway obstruction related to a blood clot which led to hypoxemia and subsequent cardiac arrest. Further review revealed Patient #1 had a bronchoscopy on 05/11/15 which revealed clotted blood in the trachea and a tumor. Physician progress notes, on 05/11/15 at 5:57 PM, stated the bronchoscopy showed evidence of a clot which may have been the consequence of bleeding from his/her tumor, thus provoking bronchospasm. Physician progress notes, on 05/12/15 at 12:59 PM, revealed Patient #1 had possible Anoxic Brain Injury related to the intubation on 05/11/15 (it took fifteen (15) minutes due to massive hemoptysis). Patient #1 received multiple units of red blood cells and platelets, but he/she expired on 05/12/15 at 8:24 PM. The record further revealed the cause of death was pulmonary hemorrhage.

Interview with RN #2, on 07/01/15 at 3:10 PM, revealed he did not remember getting an albuterol inhaler for Patient #1, on 05/09/15 at 5:17 PM, but stated he would have assessed and given medications on that day to Patient #1. He further revealed he had seen respiratory inhalers left at the patient's bedside.

Interview with RN #4, on 07/01/15 at 5:30 PM, revealed albuterol inhalers were kept at the bedside and obtained from the Pyxis (a medication delivery system on each nursing unit). He further stated he could not remember anything specific about Patient #1's inhaler and did not know if the physician wrote an order for it to be at the bedside but believed the physician would be aware the inhaler was at the bedside. He further revealed he had never charted the self-administration of a PRN inhaler.

Interview with RN #3, on 07/07/15 at 8:07 AM, revealed she was working on 6 North the 7P to 7A shift the evening of 05/10/15 to the morning of 05/11/15, but was not the primary RN for Patient #1. She further revealed she responded to a call light from Patient #1, wanting another albuterol MDI. RN #3 then stated she checked the counter of the MDI, and it was zero (0). She then called pharmacy for another inhaler and was instructed to get one from the Pyxis, which she did and gave to the patient. At that time, Patient #1 was in no respiratory distress. She further revealed she was present for the code, and the patient had done a complete turn around in his/her condition. RN #3 also revealed she was unaware of a policy on self-administration of medications; but she stated if the patient was ambulatory, cognizant, and knew how to use the inhaler, it could be left at the bedside. She stated she did not usually monitor the use of inhalers at the bedside by looking at the counter on the MDI during her routine assessment of the patients unless the patient said it was gone. RN #3 revealed if a patient was using more than ordered, she would determine their respiratory status and re-educate on its use. She then stated she did not know if there was a protocol for which medications could be kept at the bedside. RN #3 then said there was a possibility that overdosage could occur with self-administered bedside medications, but if safeguards were in place, it should not present a problem.

Interview with RN #1, on 07/07/15 at 11:39 per telephone, revealed she was Patient #1's primary RN the 7PM to 7AM shift the evening of 05/10/15 going into the AM of 05/11/15. She stated she did not remember anything about Patient #1 having an inhaler, it being on the MAR, or asking the patient about it. RN #1 then revealed she had also been Patient #1's nurse when he/she arrived on the floor on 05/08/15, and his/her respiratory status had improved as he/she was not on a oxygen rebreather mask and his/her oxygen saturation levels were higher. She stated the patient also reported feeling improved. RN #1 then revealed on 05/11/15 at 1:15 AM she was contacted by central telemetry monitoring that the patient's heart rate had dropped to 40 BPM at which time she went into the patient's room and found him/her unresponsive with copious amounts of blood coming out of his/her mouth. She then revealed she called the code and help transport the patient to ICU at which point her care stopped for Patient #1. RN #1 then stated MDI's were usually left at the bedside. If the order was for PRN, the nurse should assess whether it was needed and chart on the MAR when a dose was self-administered. She revealed she was not familiar with a policy for self-administration, and physicians did not write orders to leave inhalers at the bedside for self-administration. She further revealed if she knew a patient was on an inhaler from home, she would assess to see if he/she knew about its use.

Interview with Patient #1's physician, on 07/08/15 at 10:00 AM, revealed he did not recall ordering the albuterol MDI on 05/09/15 at 12:15 PM. He further revealed these inhalers could be safely placed at the bedside, and he did not write an order for this to occur. He further revealed he did not recall being notified by nursing that Patient #1 was taking more doses than prescribed, and he should have been notified. The physician stated if he had been notified he would have looked for other treatments to alleviate Patient #1's SOB, instructed him/her to to decrease the use, and assessed why he/she was using more than the prescribed dose because this inhaler should not be used more frequently than was ordered. He then revealed the usual side effects of overdosage of the albuterol MDI would be anxiety, tremors, and tachycardia. The physician stated Patient #1 was very sick with advanced lung cancer, and when he/she was admitted he/she was very SOB. He revealed Patient #1's treatment, among other things, consisted of albuterol nebulizer treatments, transfusion of packed red blood cells and platelets, and intravenous fluid administration. The physician further revealed Patient #1 had responded well to treatment, and the last time he saw him/her, on 05/10/15, the patient was sitting up and talking with only a little SOB. He further revealed he found out in the AM of 05/11/15 that Patient #1 had coded and was in the ICU. The physician then stated Patient #1 had hemoptysis, very low platelets, and an invasive lung tumor which very possibly caused him/her to hemorrhage from the tumor. He then revealed it was very unlikely the overdosage of the albuterol MDI contributed to the code event or Patient #1's demise.

2. Review of Patient #11's medical record revealed he/she was admitted on 06/24/15 with diagnoses including Shortness of Air and history of Lung and Renal Transplants and was ordered an albuterol MDI two (2) inhalations every four (4) hours PRN and a Dulera inhaler two (2) inhalations every twelve (12) hours. There was no order for self-administration at the bedside. Further review revealed the patient had been on these medication at home. The record also revealed six (6) doses were documented on the MAR for the albuterol inhaler, and all doses were documented for Dulera, but there was no specific teaching of using the inhalers documented in the nurses notes or an evaluation of the patient's ability to self-medicate.

Observation of Patient #11's room, on 07/07/15 at 10:30 AM, revealed a Dulera inhaler was in the room in a drawer.

Interview, on 07/07/15 at 10:35 AM, revealed Patient #11 had been asked by the nurses to let them know when he/she took a dose of the inhalers. He/she also stated the albuterol inhaler had been in the room but had been removed by nursing staff.

3. Review of Patient #12's medical record revealed he/she was admitted on 07/01/15 with diagnoses of Asthma, Abdominal Pain, and an Ovarian Mass and was ordered an albuterol MDI two (2) inhalations every four (4) hours PRN on 07/01/15 at 2:55 PM. There was no order for self-administration at the bedside. Further review revealed the patient had been on this medication at home. The record also revealed there was no specific teaching of using the MDI documented in the nurses notes or an evaluation of the patient's ability to self-medicate; however, all doses were charted on the MAR as done by the patient or refused.

Observation of Patient #12's room, on 07/07/15 at 11:50 AM, revealed there was no albuterol MDI at the bedside.

Interview, on 07/07/15 at 11:55 AM, with Patient #12 revealed he/she had been self-administering the MDI but nursing staff had removed it from the room. He/she further revealed he/she was educated on the MDI's use, and he/she informed nursing after use of the MDI.

4. Review of Patient #14's medical record revealed he/she was admitted on 06/24/15 with diagnoses of Sepsis and history of Double Lung Transplant and was ordered an albuterol MDI two (2) inhalations every four (4) hours PRN on 06/24/15 at 3:54 PM. There was no order for self-administration at the bedside. Further review revealed the patient had been on this medication at home. There was no specific education on the use of the MDI documented in the nurses notes or an evaluation of the patient's ability to self-medicate. This medication had not been used.

Observation of Patient #14's room, on 07/08/15 at 3:20 PM, revealed there was an albuterol MDI on the bedside table.

Interview, on 07/08/15 at 3:25 PM, with Patient #14 revealed he/she had not received any doses of the albuterol MDI, but nursing staff asked if he/she had used the MDI and instructed him/her to let them know if he/she did use the inhaler.

5. Review of Patient #15's medical record revealed he/she was admitted on 07/01/15 with diagnoses of Coronary Artery Disease and Chronic Obstructive Pulmonary Disease (COPD) and was ordered an albuterol MDI two (2) inhalations every four (4) hours PRN and a Dulera inhaler two (2) inhalations every twelve (12) hours on 07/01/15 at 9:27 PM. There was no order for self-administration at the bedside. Further review revealed the patient had been on these medications at home. There was no documentation of specific education about the use of these medications or an evaluation of the patient's ability to self-medicate.

Observation of Patient #15's room, on 07/08/15 at 3:35 PM, revealed both the Dulera inhaler and the albuterol inhaler were on the bedside table.

Interview with Patient #15, on 07/08/15 at 3:40 PM, revealed nursing staff instructed the patient on their use and asked him/her about their use.

Interview with RN #5, on 07/06/15 at 12:25 PM, revealed respiratory inhalers were kept at the bedside or in the Pyxis, and it's use could be monitored by the counting of remaining capsules or reviewing the counter for doses left, depending on the type of inhaler. He further revealed dosages taken should be documented on the MAR as being self-administered. In addition, RN #5 stated the physician did not write an order for self-administration.

Interview with RN #6, on 07/06/15 at 12:45 PM, revealed respiratory inhalers were kept at the bedside without a physician order to allow it. She further revealed the inhaler's use should be documented on the MAR, and the nurse should observe its use. Also, RN #6 stated the correct use of the MDI could not really be monitored, and nursing staff would have to trust the patient or remove the inhaler from the room if overdosage were suspected.

Interview with the Clinical Nurse Manager (CNM) of 6 North, on 07/06/15 at 1:10 PM, revealed respiratory inhalers were kept at the bedside and would be ordered by the physician. She also stated nursing staff would have to trust the patient to let nursing know when it was taken. The CNM revealed if an overdosage was suspected, the nurse should assess the patient's respiratory status, notify the physician, pharmacy, and the CNM, and the inhaler placed in the Pyxis. She then revealed the patient should be re-educated on the use of the MDI.

Interview with RN #7, on 07/07/15 at 10:50 AM, revealed it was a standard practice to leave respiratory inhalers at the bedside. She further revealed she believed it was a safe practice if the patient had been taking the medication at home and the patient's cognitive ability was intact.

Interview with RN #8, on 07/07/15 at 11:20 PM, revealed inhalers were not kept at the bedside of the patient. She further revealed it would be difficult to document the dosage taken accurately. RN #8 stated she had never observed a physician order for an inhaler to be left at the bedside.

Interview with the Assistant Director of the Hospital, on 07/06/15 at 4:00 PM, revealed there was not a comprehensive policy or procedure on self-administered medications. She further revealed there had been one, but it had been integrated into other policies. She then revealed the facility should have a consistent, comprehensive policy and procedure for self-administration of medications with all nursing staff following the same process.

Based on observation, interview, record review, and review of facility's policies and documents, it was determined the facility failed to ensure nursing supervision of self-administered medications for one (1) of ten (10) sampled patients, Patient #1, who self-administered thirty (30) doses of a respiratory inhaler (Albuterol) in a twenty-eight (28) hour period when the ordered PRN (as needed) doses would have been a maximum of seven (7) and for four (4) of five (5) unsampled patients, Patients #11, #12, #14, and #15 who were observed or interviewed with a respiratory inhaler at the bedside for self-administration. (Refer to A412).

Patient #1 was admitted to the facility on 05/08/15 with diagnoses which included Stage IV Squamous Cell Cancer of the Lung, Anemia, Hyponatremia, Hyperkalemia, Acute Kidney Injury, Syncope, Hemoptysis, and Dehydration. Patient #1 was ordered an albuterol inhaler two (2) inhalations every four (4) hours as needed for shortness of breath.

On 5/09/15 at 5:17 PM Patient #1 was given, by Registered Nurse (RN) #1 an albuterol inhaler to be left at the bedside with sixty (60) inhalations. On 05/10/15 at 9:09 PM, Patient #1 was given a second inhaler by RN #3 who observed the first inhaler had no doses remaining. There was no physician's order for the medication to be left at the patient's bedside for self-administration. Also, there were no doses charted on the medication administration record (MAR); there was no assessment that Patient #1 could safely self-administer the inhaler; and there was no specific education given to the patient on the inhaler documented in the nurses notes.

Patient #11, #12, #14, and #15 were unsampled patients that had at least one (1) respiratory inhaler left at the bedside without a physician's order to do so. They also had no teaching on the use of the inhaler documented in their medical record and there was no documented assessment of the patient's ability to self-medicate documented in the medical record.

The failure of the facility to provide a consistent, comprehensive policy for self-medication that provided a process for nursing to effectively monitor patients with medications left at the bedside to ensure safe administration placed Patient #1, #11, #12, #14, and #15 at risk for side effects from overdosage of albuterol and/or Dulera inhalers. (Refer to A0144)

Based on observation, interview, review of facility's policies and documents, and review of medication package inserts, it was determined the facility failed to ensure medications left at the patient's bedside were ordered to be at the bedside, monitored for use, verified that the patient had the ability to safely administer them, patient-educated on their use, and/or charted on the medication administration record (MAR) for one (1) of ten (10) sampled patients, Patient #1 and four (4) of five (5) unsampled patients, Patients #11, #12, #14, and #15.

The findings include:

Review of the facility's policy, "Administration and Documentation of Medications", policy ND14-01, review/revision date 01/04/13, revealed medications that were ordered specifically by the licensed independent practitioner to be kept at the bedside would be documented in the PRN (as needed) section of the MAR.

Review of the facility's policy, "Administration of Medications Brought into the Hospital by Patients", policy ND14-04, review/revision date 03/2011, revealed all medications taken at home shall be documented in the patient's medication history, and any administration of the medication shall be recorded on the patient's MAR. The policy further revealed upon receiving an order for self-medication, the pharmacy shall enter all medications involved with the appropriate dosages, etc. which would allow the medication to be on the daily MAR for the nursing staff to record doses the patient had taken. Also, if the patient's supply of personal medication was exhausted, the pharmacy would supply the patient with medication, per physician's order. The pharmacy staff would note in the MAR that the medication was to be self-administered. In addition, the policy also stated nursing would provide the patient with instructions and monitor the self-administration of medications to include verifying that the patient had the ability to safely and competently administer the medication; instructing and documenting the patient and the name of the medication, method of administration, dose, reason for use, and frequency of administration; and alerting the patient of potential adverse reactions and the importance of reporting any problems to the nurse.

Review of the package insert for the albuterol sulfate inhalation aerosol (ProAir, IVAX Laboratories, Inc., 2005) revealed it was a beta-adrenergic agonist (used to relax airways and make breathing easier) prevention of acute episodes of bronchospasm, the usual dosage was two (2) inhalation repeated every four (4) to six (6) hours, and more frequent administration or a larger number of inhalations was not recommended. Also, the insert stated the expected symptoms with overdosage were seizures, angina, hypertension or hypotension, tachycardia, with rates up to two hundred (200) beats per minute, arrhythmias, nervousness, headache, tremor, dry mouth, palpitation, nausea, fatigue, malaise, insomnia, and hypokalemia. It further revealed cardiac arrest and even death may be associated with abuse of the inhaler.

Review of the package insert for Dulera inhaler (Merck & Co.Inc., 2010, a combination product that contained a corticosteroid to decrease inflammation and a long-acting beta-adrenergic agonist) revealed it was used for treatment of asthma in patient twelve (12) years of age or older. It also revealed Dulera should not be used more often than recommended. It stated clinically significant cardiovascular effects and fatalities had been reported in association with excessive use of inhaled sympathomimetic drugs (mimic the effects of stimulation of the sympathetic nervous system such as tachycardia and hypertension). Also, the insert stated the expected symptoms with overdosage were seizures, angina, hypertension or hypotension, tachycardia, with rates up to two hundred (200) beats per minute, arrhythmias, nervousness, headache, tremor, dry mouth, palpitation, nausea, fatigue, malaise, and insomnia.

Review of the "All Transaction Activity Detail Report, 05/07/15 - 05/12/15, Patient #1", revealed he/she was charged for an albuterol MDI with sixty (60) inhalations per unit on 05/09/15 at 5:17 PM, and RN #2 removed one from the Pyxis for the patient at this time. Then again, Patient #1 was charged for an albuterol MDI on 05/10/15 at 9:09 PM, and RN #3 removed one from the Pyxis at the same time. Therefore, thirty (30) doses or sixty (60) inhalations were self-administered by Patient #1 in an approximate twenty-eight (28) hour period; when the ordered dose would have been seven (7) or fourteen (14) inhalations.

1. Review of Patient #1's medical record revealed he/she was admitted on 05/08/15 to a room on 6 North with diagnoses which included Stage IV Squamous Cell Cancer of the Lung, Anemia, Hyponatremia, Hyperkalemia, Acute Kidney Injury, Syncope, Hemoptysis, and Dehydration. On 05/09/15 at 12:15 PM, Patient #1's physician ordered Albuterol Inhalation Metered Dose Inhaler (MDI) two (2) inhalations every four (4) hours PRN (as needed) for shortness of breath (SOB); the record also revealed he/she was on this medication at home. Further review revealed the order for the albuterol inhaler did not state Patient #1 could keep this medication at his/her bedside. Review of the MAR revealed this medication was listed as a PRN medication, and there was no documentation on the MAR for 05/09/15 or 05/10/15 that Patient #1 received any doses of the MDI. There was also no documentation that Patient #1 was assessed as to his/her ability to self-medicate and no documented evidence of teaching by the nurses about this medication, for instance the dose, frequency, and adverse effects. The record further revealed on 05/11/15 at 1:15 AM Central Monitoring (monitored patients on telemetry) informed Registed Nurse (RN) #1 that Patient #1's heart rate was forty (40) beats per minute (BPM), and upon her entering the patient's room, she found him/her unresponsive and without a pulse. Cardiopulmonary resuscitation (CPR) was initiated and a code called. Patient #1 was intubated at 1:23 AM and a spontaneous pulse returned at 1:33 PM; at 1:55 AM the pulmonary team and the code team transported Patient #1 to the Intensive Care Unit (ICU). Further review revealed at this point his/her heart rate was 189 BPM and he/she was unresponsive with a Glasgow Coma Scale (GCS; a scale from zero (0) to fifteen (15) that measures neurological status; the higher the score, the less deficits the patient has) score of three (3). Further review revealed Patient #1 had the albuterol MDI ordered as on the floor when admitted to the ICU; then on 05/12/15 at 8:10 AM the doses were changed from PRN to scheduled doses every four (4) hours which were administered by respiratory therapy. In addition, the ICU history and physical, dated 05/11/15 at 2:13 AM, revealed the cardiopulmonary arrest was secondary to an airway obstruction related to a blood clot which led to hypoxemia and subsequent cardiac arrest. Further review revealed Patient #1 had a bronchoscopy on 05/11/15 which revealed clotted blood in the trachea and a tumor. Physician progress notes, on 05/11/15 at 5:57 PM, stated the bronchoscopy showed evidence of a clot which may have been the consequence of bleeding from his/her tumor, thus provoking bronchospasm. Physician progress notes, on 05/12/15 at 12:59 PM, revealed Patient #1 had possible Anoxic Brain Injury related to the intubation on 05/11/15 (it took fifteen (15) minutes due to massive hemoptysis). Patient #1 received multiple units of red blood cells and platelets, but he/she expired on 05/12/15 at 8:24 PM. The record further revealed the cause of death was pulmonary hemorrhage.

Interview with RN #2, on 07/01/15 at 3:10 PM, revealed he did not remember getting an albuterol inhaler for Patient #1, on 05/09/15 at 5:17 PM, but revealed he would have assessed the patient and given medications on that day to Patient #1. He further revealed he had seen respiratory inhalers left at the patient's bedside.

Interview with RN #4, on 07/01/15 at 5:30 PM, revealed albuterol inhalers were kept at the bedside and obtained from the Pyxis (a medication delivery system on each nursing unit). He further stated he could not remember anything specific about Patient #1's inhaler and did not know if the physician wrote an order for it to be at the bedside but believed the physician should be aware the inhaler was at the bedside. He further revealed he had never charted the self-administration of a PRN inhaler.

Interview with RN #3, on 07/07/15 at 8:07 AM, revealed she was working on 6 North the 7 PM to 7 AM shift the evening of 05/10/15 to the morning of 05/11/15, but was not the primary RN for Patient #1. She further revealed she responded to a call light from Patient #1, wanting another albuterol MDI. RN #3 then stated she checked the counter of the MDI, and it was zero (0). She then called pharmacy for another inhaler and was instructed to get one from the Pyxis, which she did and gave to the patient. At that time, Patient #1 was in no respiratory distress. She further revealed she was present for the code, and the patient had done a complete turn around in his/her condition. RN #3 also revealed she was unaware of a policy on self-administration of medications; but she stated if the patient was ambulatory, cognizant, and knew how to use the inhaler, it could be left at the bedside. She stated she did not usually monitor the use of inhalers at the bedside by looking at the counter on the MDI during her routine assessment of the patients unless the patient said it was gone. RN #3 revealed if a patient was using more than ordered, she would determine their respiratory status and re-educate on its use. She then stated she did not know if there was a protocol for which medications could be kept at the bedside. RN #3 than said there was a possibility the overdosage could occur with self-administered bedside medications, but if safeguards were in place, it should not present a problem.

Interview with RN #1, on 07/07/15 at 11:39 per telephone, revealed she was Patient #1's primary RN the 7 PM to 7 AM shift the evening of 05/10/15 going into the AM of 05/11/15. She stated she did not remember anything about Patient #1 having an inhaler, it being on the MAR, or asking the patient about it. RN #1 then revealed she had also been Patient #1's nurse when he/she arrived on the floor on 05/08/15, and his/her respiratory status had improved as he/she was not on a oxygen rebreather mask and his/her oxygen saturation levels were higher. She stated the patient also reported feeling improved. RN #1 then revealed on 05/11/15 at 1:15 AM she was contacted by central telemetry monitoring that the patient's heart rate had dropped to 40 Beats per Minute (BPM) at which time she went into the patient's room and found him/her unresponsive with copious amounts of blood coming out of his/her mouth. She then revealed she called the code and help transport the patient to ICU at which point her care stopped for Patient #1. RN #1 then stated MDIs were usually left at the bedside. If the order was for PRN, the nurse should assess whether it was needed and chart on the MAR when a dose was self-administered. She revealed she was not familiar with a policy for self-administration, and physicians did not write orders to leave inhalers at the bedside for self-administration. She further revealed if she knew a patient was on an inhaler from home, she would assess to see if he/she knew about its use and this should all be documented in the medical record.

Interview with Patient #1's physician, on 07/08/15 at 10:00 AM, revealed he did not recall ordering the albuterol MDI on 05/09/15 at 12:15 PM. He further revealed these inhalers could be safely placed at the bedside, and he did not write an order for this to occur. He further revealed he did not recall being notified by nursing that Patient #1 was taking more doses than prescribed, and he should have been notified as this should be part of the nursing assessment. The physician stated if he had been notified he would have looked for other treatments to alleviate Patient #1's Short of Breath (SOB), instructed him/her to to decrease the use, and assessed why he/she was using more than the prescribed dose because this inhaler should not be used more frequently than was ordered. He then revealed the usual side effects of overdosage of the albuterol MDI would be anxiety, tremors, and tachycardia. The physician stated Patient #1 was very sick with advanced lung cancer, and when he/she was admitted he/she was very SOB. He revealed Patient #1's treatment, among other things, consisted of albuterol nebulizer treatments, transfusion of packed red blood cells and platelets, and intravenous fluid administration. The physician further revealed Patient #1 had responded well to treatment, and the last time he saw him/her, on 05/10/15, the patient was sitting up and talking with only a little SOB. He further revealed he found out in the AM of 05/11/15 that Patient #1 had coded and was in the ICU. The physician then stated Patient #1 had hemoptysis, very low platelets, and an invasive lung tumor which very possibly caused him/her to hemorrhage from the tumor. He then revealed it was very unlikely the overdosage of the albuterol MDI contributed to the code event or Patient #1's demise.

2. Review of Patient #11's medical record revealed he/she was admitted on 06/24/15 with diagnoses including Shortness of Air and history of Lung and Renal Transplants and was ordered an albuterol MDI two (2) inhalations every four (4) hours PRN and a Dulera inhaler two (2) inhalations every twelve (12) hours . There was no order for self-administration at the bedside. Further review revealed the patient had been on these medication at home. The record also revealed six (6) doses were documented on the MAR for the albuterol inhaler, and all doses were documented for Dulera, but there was no specific teaching of using the inhalers documented in the nurses notes or an evaluation of the patient's ability to self-medicate.

Observation of Patient #11's room, on 07/07/15 at 10:30 AM, revealed a Dulera inhaler was in the room in a drawer.

Interview with Patient #11, on 07/07/15 at 10:35 AM, revealed Patient #11 had been asked by the nurses to let them know when he/she took a dose of the inhalers. He/she also stated the albuterol inhaler had been in the room but had been removed by nursing staff that day.

3. Review of Patient #12's medical record revealed he/she was admitted on 07/01/15 with diagnoses of Asthma, Abdominal Pain, and an Ovarian Mass and was ordered an albuterol MDI two (2) inhalations every four (4) hours PRN on 07/01/15 at 2:55 PM. There was no order for self-administration at the bedside. Further review revealed the patient had been on this medication at home. The record also revealed there was no specific teaching of using the MDI documented in the nurses notes or an evaluation of the patient's ability to self-medicate; however, all doses were charted on the MAR as done by the patient or refused.

Observation of Patient #12's room, on 07/07/15 at 11:50 AM, revealed there was no albuterol MDI at the bedside.

Interview with Patient #12, on 07/07/15 at 11:55 AM, revealed he/she had been self-administering the MDI but nursing staff had removed it from the room. He/she further revealed he/she was educated on the MDI's use, and he/she informed nursing after use of the MDI.

4. Review of Patient #14's medical record revealed he/she was admitted on 06/24/15 with diagnoses of Sepsis and history of Double Lung Transplant and was ordered an albuterol MDI two (2) inhalations every four (4) hours PRN on 06/24/15 at 3:54 PM. There was no order for self-administration at the bedside. Further review revealed the patient had been on this medication at home. There was no specific education on the use of the MDI documented in the nurses notes or an evaluation of the patient's ability to self-medicate. This medication had not been used.

Observation of Patient #14's room, on 07/08/15 at 3:20 PM, revealed there was an albuterol MDI on the bedside table.

Interview with Patient #14, on 07/08/15 at 3:25 PM, revealed he/she had not received any doses of the albuterol MDI, but nursing staff asked if he/she had used the MDI and instructed him/her to let them know if he/she does use the inhaler.

5. Review of Patient #15's medical record revealed he/she was admitted on 07/01/15 with diagnoses of Coronary Artery Disease and Chronic Obstructive Pulmonary Disease (COPD) and was ordered an albuterol MDI two (2) inhalations every four (4) hours PRN and a Dulera inhaler two (2) inhalations every twelve (12) hours on 07/01/15 at 9:27 PM. There was no order for self-administration at the bedside. Further review revealed the patient had been on these medications at home. There was no documentation of specific education about the use of these medications or an evaluation of the patient's ability to self-medicate.

Observation of Patient #15's room, on 07/08/15 at 3:35 PM, revealed both the Dulera inhaler and the albuterol inhaler were on the bedside table.

Interview with Patient #15, on 07/08/15 at 3:40 PM, revealed nursing staff instructed the patient on their use and asked him/her about their use.

Interview with RN #5, on 07/06/15 at 12:25 PM, revealed respiratory inhalers were kept at the bedside or in the Pyxis, and its use could be monitored by the counting of remaining capsules or reviewing the counter for doses left, depending on the type of inhaler. He further revealed dosages taken should be documented on the MAR as being self-administered. In addition, RN #5 stated the physician did not write an order for self-administration.

Interview with RN #6, on 07/06/15 at 12:45 PM, revealed respiratory inhalers were kept at the bedside without a physician order to allow it. She further revealed the inhaler's use should be documented on the MAR, and the nurse should observe its use. Also, RN #6 stated the correct use of the MDI could not really be monitored, and nursing staff would have to trust the patient or remove the inhaler from the room if overdosage were suspected.

Interview with the Clinical Nurse Manager (CNM) of 6 North, on 07/06/15 at 1:10 PM, revealed respiratory inhalers were kept at the bedside and would be ordered by the physician. The CNM revealed if an overdosage were suspected, the nurse should assess the patient's respiratory status, notify the physician, pharmacy, and the CNM, and the inhaler placed in the Pyxis. She also stated nursing staff would have to trust the patient to let nursing know when it was taken. She then revealed the patient should be re-educated on the use of the MDI.

Interview with RN #7, on 07/07/15 at 10:50 AM, revealed it was a standard practice to leave respiratory inhalers at the bedside. She further revealed she believed it was a safe practice if the patient had been taking the medication at home and the patient's cognitive ability was intact.

Interview with RN #8, on 07/07/15 at 11:20 PM, revealed inhalers were not kept at the bedside of the patient. She further revealed it would be difficult to document the dosage taken accurately. RN #8 stated she had never observed a physician order for an inhaler to be left at the bedside.

Interview with the Assistant Director of the Hospital, on 07/06/15 at 4:00 PM, revealed there was not a comprehensive policy or procedure on self-administered medications. She further revealed there had been one, but it had been integrated into other policies. She then revealed the facility should have a consistent, comprehensive policy and procedure for self-administration of medications with all nursing staff following the same process.

Based on interview, medical record review, and review of facility's policies and documents, it was determined the facility failed to ensure the pharmacy provided oversight for the dispensing of an inhaled medication for one (1) of ten (10) sampled patients, Patient #1.
The findings include:

Review of facility policy, "Dispensing of Drugs to Patient Care Units and Requisitioning of Drugs to Other Using Areas", policy PH-04-08, dated 11/2009, revealed drugs were dispensed to patients on nursing care units upon receipt of a physician's medication order. The unit dose system and Pyxis distribution was in effect throughout the facility. Further review revealed the process for obtaining medications at the nursing unit by 1) the physician would enter an order via the computerized prescriber order entry system; 2) the order would be verified by a pharmacist; 3) first doses could be obtained from Pyxis if stocked there; and 4) missing doses were requested by the nurse whereby the pharmacist would review the patient's profile and investigate the reason for the missing dose prior to dispensing a subsequent dose.

Review of the "All Transaction Activity Detail Report, 05/07/15 - 05/12/15, Patient #1", revealed he/she was charged for an albuterol MDI with sixty (60) inhalations per unit on 05/09/15 at 5:17 PM, and RN #2 removed one from the Pyxis for the patient at this time. Then again, Patient #1 was charged for an albuterol MDI on 05/10/15 at 9:09 PM, and RN #3 removed one from the Pyxis at the same time. Therefore, thirty (30) doses or sixty (60) inhalations were self-administered by Patient #1 in an approximate twenty-eight (28) hour period; when the ordered dose would have been seven (7) or fourteen (14) inhalations.

Review of Patient #1's medical record revealed he/she was admitted on 05/08/15 to a room on 6 North with diagnoses which included Stage IV Squamous Cell Cancer of the Lung, Anemia, Hyponatremia, Hyperkalemia, Acute Kidney Injury, Syncope, Hemoptysis, and Dehydration. On 05/09/15 at 12:15 PM, Patient #1's physician ordered Albuterol Inhalation Metered Dose Inhaler (MDI) two (2) inhalations every four (4) hours PRN (as needed) for shortness of breath (SOB); the record also revealed he/she was on this medication at home. Further review revealed the order for the albuterol inhaler did not state Patient #1 could keep this medication at his/her bedside. Review of the MAR revealed this medication was listed as a PRN medication, and there was no documentation on the MAR for 05/09/15 or 05/10/15 that Patient #1 received any doses of the MDI. There was also no documentation that Patient #1 was assessed as to his/her ability to self-medicate and no documented evidence of teaching by the nurses about this medication, for instance the dose, frequency, and adverse effects. Further review revealed Patient #1 had the albuterol MDI ordered as on the floor when admitted to the ICU on 05/11/15; then on 05/12/15 at 8:10 AM the doses were changed from PRN to scheduled doses every four (4) hours which were administered by respiratory therapy.

Interview with Registered Nurse (RN) #2, on 07/01/15 at 3:10 PM, revealed he did not remember getting an albuterol inhaler for Patient #1, on 05/09/15 at 5:17 PM, but revealed he would have assessed the patient and given medications on that day to Patient #1. He further revealed he had seen respiratory inhalers left at the patient's bedside.

Interview with RN #3, on 07/07/15 at 8:07 AM, revealed she was working on 6 North the 7 PM to 7 AM shift the evening of 05/10/15 to the morning of 05/11/15, but was not the primary RN for Patient #1. She further revealed she responded to a call light from Patient #1, wanting another albuterol MDI. RN #3 then stated she checked the counter of the MDI, and it was zero (0). She then called pharmacy for another inhaler and was instructed to get one from the Pyxis, which she did and gave to the patient. At that time, Patient #1 was in no respiratory distress. She stated she did not usually monitor the use of inhalers at the bedside by looking at the counter on the MDI during her routine assessment of the patients unless the patient said it was gone. RN #3 revealed if a patient was using more than ordered, she would determine their respiratory status and re-educate on its use.

Interview with the Director of Pharmacy, on 07/08/15 at 10:45 AM, revealed the albuterol MDI Patient #1 was ordered was a sixty (60) inhalation unit, and if the nurse called the pharmacy and asked for a refill, she would not expect a pharmacy technician or pharmacist to question the use because there were so many reasons for a replacement; for example, the MDI could be lost, misplaced, or sent home with family. She further revealed she would expect the nurse to assess the situation if the MDI was having to be replaced more frequently than ordered. The Director then stated there were some medications that an order for an early replacement would trigger an inquiry, such as special oral medications that are prepared in the pharmacy. She further revealed for a replacement MDI she would have expected the pharmacy staff to have confirmed that it was ordered for Patient #1, but she would not have expected him/her to question whether it
was appropriate for the patient to have another inhaler taken out of the Pyxis stock; the inhalers were stocked in the Pyxis for nurses to get another one when needed for a patient. She stated she did not think the pharmacy staff should have or would have identified the high usage on the MDI for Patient #1. The Director then said perhaps the pharmacy would have identified the overusage if it had been a medication with more serious side effects, but for the albuterol MDI, as long as the patient was tolerating their increased usage, there should not really have been a problem. She further revealed, as far as the package insert stating fatalities had been reported with excessive use, it was not because the overdosing caused the death, but because the condition requiring the patient to use the MDI more frequently than ordered had worsened.

Based on interview, medical record review, and review of facility's policies and documents, it was determined the facility failed to ensure effective discharge planning was done for one (1) of ten (10) sampled patients, Patient #2, as evidenced by the facility's failure to correctly schedule follow-up outpatient appointments.

The findings include:

Review of facility policy, "Discharges-Hospital Inpatient", policy A02-005, review/revision date 07/2013, revealed its purpose was to provide guidelines for patient discharge from UK HealthCare hospitals. It further revealed the attending physician would dictate and make available the discharge summary and other forms such as return to clinic, prescriptions, and specific home care needs of the patient.

Review of the "2015 Annual PCA Competency" for unit administrative staff revealed the staff would be assessed for competency by demonstration in the area of "Perfect Discharge" which included making follow-up appointments for patients and giving them the phone number of the clinic or office to call if needed.

Review of Patient #2's medical record revealed he/she was admitted as an inpatient from the Emergency Department (ED) on 04/08/15 with a diagnosis of Myasthenia Gravis (a chronic autoimmune neuromuscular disease characterized by varying degrees of weakness of the skeletal muscles which could be diagnosed by a Repetitive Nerve Stimulation (RNS) test or a more definitive Single Fiber Electromyography (EMG)). The record further revealed, after discharge, on 04/20/15, Patient #2's status was changed from inpatient to observation; the discharge date was 04/10/15. The record also showed "Patient Discharge Instructions" were given to Patient #2 on 04/10/15 at 8:18 PM by Registered Nurse (RN) #1. Discharge instructions under "Follow Up" were 1) an EMG clinic appointment at Kentucky Neuroscience Institute (KNI) on Wednesday, 04/15/15 at 10:00 AM (no telephone number or address listed) and 2) a Neurology clinic appointment on 04/22/15 with no time, address, or telephone number listed. The record further revealed under "Information Reviewed/Patient Received" follow-up clinic appointments were entered, and under "Discharge Information" it was charted discharge instructions were reviewed with patient, family, and/or significant other. In addition, the record revealed Patient #2 signed that the "Patient Discharge Instructions" had been reviewed and provided to him/her as a reference for his/her post discharge plan of care.

Interview with Patient #2, on 07/06/15 at 11:22 AM, revealed on discharge he/she was given information for two (2) clinic appointments. When Patient #2 arrived to the clinic on 04/15/15, he/she stated the clinic was unaware of his/her appointment; however, the clinic staff finally found out what had happened, and Patient #2 was seen. Patient #2 further revealed the second appointment, with the neurology clinic on 04/22/15, could not be found, and he/she could not get another appointment for five (5) months. He/she further revealed he/she wondered what happened to the 04/22/15 appointment and thought perhaps it had been cancelled by someone.

Interview with the Patient Access Manager (PAM) for KNI, on 07/06/15 at 3:44 PM, revealed she oversaw the scheduling process, and Neurology Technician (NT) #1 had scheduled a test for Patient #2 on 04/14/15 which had been done on 04/15/15. On 04/20/15, Patient #2's neurologist thought an appointment with the neuromuscular doctors had been scheduled for 04/22/15, but one had not been scheduled. The PAM stated KNI should have received a call from the hospital unit clerk or a FAX sent to request an appointment before Patient #2's discharge. The PAM further revealed she could not find any access points where KNI was notified of Patient #2's need for an appointment on 04/22/15; the next available appointment was 09/30/15; and Patient #2 was scheduled at that time. The PAM also stated the resident physician writing the discharge orders/summary would not have known availability of KNI appointments, so how the 04/22/15 appointment got on the discharge instructions could not be determined by her.

Interview with Registered Nurse (RN) #1, on 07/07/15 at 7:45 AM, revealed she was Patient #2's nurse on 04/10/15 from 7:00 PM to discharge, and she prepared and gave the discharge instructions. She further revealed, at that time of evening, follow-up clinic appointments would not be scheduled because the clinic would be closed; therefore, many times, in this situation, the patients would have to schedule the appointment(s) the next day. If there were dates in the appointment times, RN #1 stated, she would have assumed the day shift unit clerk would have made the appointments. She also revealed RN's did follow-up discharge phone calls to patients to see if they remembered their clinic appointments.

Interview with Unit Clerk #1, on 07/07/15 at 12:02 PM, revealed she was the unit clerk on day shift on 04/10/15. She further revealed she had not made any post-discharge clinic appointments for Patient #2.

Interview with the Clinical Nurse Manager (CNM), on 07/07/15 at 12:18 PM, revealed information from the Discharge Summary (DS) done by the physician flowed into the Discharge Instructions (DI). For follow-up clinic appointments, the DS would almost always say to follow-up at KNI in whatever timeframe the physician chose, e.g. two (2) weeks, three (3) weeks, etc.; the follow-up would not have a specific date or time. She further stated when the unit clerk saw these instructions, he/she would call the KNI for an appointment which would be put on the DI and communicated to the patient. In this instance, it appeared the physician put actual dates and times which flowed into the DI. She further stated, RN #1, who gave the DI, thought the appointments had been made, so she did not instruct Patient #2 to call KNI for appointments, and the unit clerk did not know to FAX any information about Patient #2 to KNI. The CNM further revealed she had never seen a physician put specific dates in the DS.

Interview with NT #1, on 07/08/15 at 10:23 AM, revealed Patient #2 had a Repetitive Nerve Stimulation test on 04/15/15, and it was not scheduled by him until 04/14/15; therefore, the facility did not schedule it at discharge. He further stated the patient did keep his/her appointment on 04/15/15 with the ordered test done. He further revealed he had no specific information about the 04/22/15 appointment, but stated if a patient was dissatisfied about the wait for an appointment, KNI would try to get the patient in sooner by overbooking and working the patient in, etc. NT #1 further revealed Patient #2 had a Single Fiber EMG done in December 2014, and this test was usually done annually because if it were repeated too soon, the results would likely be the same.

Based on interview and medical record review, it was determined the facility failed to ensure physician ordered respiratory therapy treatments were performed per physician orders for one (1) of ten (10) sampled patients, Patient #1.

The findings include:

Interview with the Director of Therapeutic Services, on 07/02/15 at 1:50 PM, revealed there was not a policy for respiratory therapy services concerning missed treatments.

Review of Patient #1's medical record revealed he/she was admitted on 05/08/15 to a room on 6 North with diagnoses which included Stage IV Squamous Cell Cancer of the Lung, Anemia, Hyponatremia, Hyperkalemia, Acute Kidney Injury, Syncope, Hemoptysis, and Dehydration. On 05/09/15 at 12:15 PM, Patient #1's physician ordered Albuterol/Ipratropium inhaled nebulizer treatments per respiratory therapy every four (4) hours. Further record review revealed Patient #1 missed two (2) nebulizer treatments on 05/10/15; one (1) at 8:00 AM and one (1) at 4:00 PM. The treatment missed at 8:00 AM by Respiratory Therapist (RT) #1 had a note that documented the missed treatment was due to his required presence at a code. The second missed treatment at 4:00 PM by RT #1 had a note that stated the missed treatment was due to his inability to retrieve the medication from the Pyxis (a medication delivery system on every nursing unit). The record revealed there was no attempt to make-up these missed treatments. Nurses notes, at 8:00 AM on 05/10/15, revealed Patient #1 had shallow breathing with coarse crackles in the left lower and right lower lobes. Further review revealed Respiratory Therapist did give the 12:00 PM treatment which showed he increased Patient #1's oxygen from 4.5 liters per nasal cannual to 5 liters per nasal cannula. The chart stated at the 7:35 PM treatment on 05/10/15, Patient #1 had an oxygen saturation level of 96% both pre- and post-treatment while receiving oxygen at 5 liters per nasal cannula. There was no change in breath sounds with the patient having shallow breathing with coarse crackles both pre- and post-treatment.

Additional interview with the Director of Therapeutic Services, on 07/02/15 at 1:50 PM, revealed RT #1 was no longer employed at the facility. She further revealed she could not comment on the validity of the reasons for the missed treatments because she had no way of knowing what RT #1's communication was and with whom. The Director then stated she tracked missed treatments to monitor for a pattern of increased rates. She further revealed there used to be a window for plus or minus two (2) hours from the scheduled treatment time to give a respiratory treatment; however, she stated there was not a policy for timeframes and missed treatments.