HospitalInspections.org

Based on medical record review, policy review and interview, the nursing staff has not ensured the ongoing documentation of ventilator functioning in accordance with facility policy in 3 of 4 patients receiving ventilator care.

Findings include:

Review of facility policy entitled " Adult Ventilator Management ", last reviewed October 2016 revealed the cardiopulmonary services/respiratory care will provide in-house ventilator support 24 hours per day with properly trained RN ' s monitoring ventilation with assistance and support of respiratory care practitioners during their scheduled hours and after hours on call coverage. It is noted that routine checks, at least every two hours, of patient-ventilator system performance are mandatory.

Review of facility policy entitled " Ventilated Patients, Care of, and Prevention of Ventilator-Associated Pneumonia ", last reviewed October 2016, revealed ventilators will be checked no less than every two hours for proper function by respiratory therapy staff or ICU nursing staff and recorded in Meditech under RT documentation interventions.

Review of RT documentation for Patient #1 revealed a ventilator check was conducted on 5/15/17 at 10:30pm, with the next documented check on 5/16/17 at 7:35am.

Review of RT documentation for Patient #3 revealed a ventilator check was conducted on 6/22/17 at 12:57am, with the next documented check at 7:30am. On 6/26/17, ventilator checks were documented at 3:44pm and 8:23pm, followed by a check on 6/27/17 at 12:35am and 7:35am.

Review of RT documentation for Patient #10 revealed a ventilator check was conducted on 7/8/17 at 8:00pm, with the next documented check on 7/9/17 at 2:07am, followed by one at 6:00am. On 7/11/17 a ventilator check was conducted at 12:00am with the next documented check at 5:30am, followed by one at 3:45pm. On 7/12/17 a ventilator check was conducted at 12:00am, with the next documented check at 5:45am.

Interview with Staff (C) and (D) on 7/13/17 at 10:00am verified that the nursing staff are not consistently documenting ventilator checks every two hours as required.

Based on observation and interview the facility does not ensure expired drugs are not available for patient use. This potentially could result in the administration of an expired medication.

Findings include:

Observation on 7/13/17 at 11:00am in the Respiratory Therapy storage area revealed (1) open and (1) closed pack of levalbuteral inhalation solution, expiration date 5/16, (1) box of cromolyn sodium inhalation, expiration date 9/16 and (4) vials of expired sodium chloride, (3) of the vials with an expiration date of 7/14 and (1) with an expiration date of 3/13.

Interview with Staff (D) on 7/13/17 at 11:00am verified the presence of expired medication.