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Based on medical record review it was determined that the nursing staff failed to obtain a physician order for treatment in one (1) of three records reviewed (Patient #31).


The findings include:

Patient #31 was admitted on February 2, 2011 with diagnoses of Seizures/Epilepsy, Acute Respiratory Failure status post tracheostomy, Pneumonia Feeding Dysfunction, history of Vagus Nerve Stimulator Implant, Hypotension, Peripheral Vascular Disease, Cardiomyopathy, Encephalopathy with history of Mental Retardation, Lupus, Anemia, and Lead Intoxication. Review of the medical record of the medical record starting May 24, 2012 at approximately 9:30 AM revealed the patient was in two (2) point upper extremity soft restraint on February 27, 2011 from 6:00 AM to 4:00 AM February 28, 28, 2011. The medical record lacked documented evidence that the nursing staff obtain an order for restraints for the 24 hour period. The nursing staff failed to obtain a physician order for restraints prior to application.


The findings were discussed with the Chief Nursing Officer on June 7, 2011.

9. Based on medical record, policy review and staff interview it was determined that that the Respiratory Therapy (RT) staff failed to followed the hospital ' s written policy related to decannulation prevention and assessment in one (1) three records reviewed (Patient #31).

The findings include:

Specialty Hospital of Washington Hadley Departmental Policy and Procedure for Respiratory Care, policy number 7360-125 entitled Decannulation Prevention revised January 31, 2011, Section one (I) Policy stipulates, " The Respiratory Therapist assigned to the patient or Lead Respirator Therapy will assess and document the patient ' s decannulation risk factor as soon as practical, but no later within twenty- four (24) hours of admission/intubation and on high risk decannulation patients on every forty-eight ( 48) basis. A decannulation risk-reassessment will be initiated by any change in patient status, such as ...agitation level or change in consciousness. The respiratory therapist will determine and communicate the decannulation risk classification level as appropriate. Based on established criteria, patients identified as " High Risk " for airway decannulation will be placed on airway precautions and interventions initiated per protocol. "

Patient #31 was admitted on February 2, 2011 with diagnoses of Seizures/Epilepsy, Acute Respiratory Failure status post Tracheotomy, Pneumonia Feeding Dysfunction, history of Vagus Nerve Stimulator Implant, Hypotension, Peripheral Vascular Disease, Cardiomyopathy, Encephalopathy with history of Mental Retardation, Lupus, Anemia, and Lead Intoxication. Review of the medical record on May 24, 2012 at approximately 9:30 AM lacked documented evidence that the Respiratory Therapy staff completed Decannulation Risk Assessment 24 hours after admission.

Further review revealed on February 26, 2011 at 8:27 AM the patient pulled out tracheostomy (trach) tube; a Code Blue was called and patient responded within one (1) minute. A note documented by the Respiratory Therapist at 8:40 AM on February 26, 2011 referenced the code was called (8:27 to 8:40 AM), trach replaced, oxygen saturation greater than 95%, trach care completed and treatment given and tolerated well post episode. The medical record lacked documented evidence of a Decannulation Risk Assessment was completed by Respiratory Therapist post decannulation and code blue. The RT staff failed to follow policy for decannulation prevention.

On May 30, June 1 and 6, 2012 telephone interviews were conducted with RT staff that was not present during the survey and onsite visit. The Director for RT Service was present with each RT staff interview. Performance improvement, decannulation risk assessment, RT staff responsibilities in a code and RT staff documentation were discussed. On June 6, 2012 at approximately 7:58 AM and 11:58AM, the Director was questioned regarding documentation of decannulation risk assessments. The Director stated that decannulation risk assessments are documented on regular progress notes, Respiratory Progress Notes and/or the Decannulation Risk Assessment Form. The Director referenced a note in which decannulation risk was discussed in a Respiratory Care Note. The Director further stated patients are " discussed in hand off of care, notes on the respiratory board, and High Risk signs posted over the patient ' s bed. There are several places RT can find information if Risk Assessment done. "

The above policy was reviewed with the Director regarding the decannulation risk assessment on admission and on a 48 basis. The Director stated that " We do not do the form every 48 hours. We do it on critical assessment and with accidental events. "

The findings were discussed, reviewed and acknowledged by the Director of RT regarding no documented decannulation risk assessment on admission, post Code Blue and every 48 hours after High Risk assessment for decannulation documented.

Further review of record after interview on June 6, 2012 revealed on April 7, 2011 at 2:45 AM revealed RT staff documented using the Respiratory Care Assessment and Progress Note " Patient decannulated herself but reinserted back successfully, as of ___ no apparent respiratory distress ... " vital signs were documented to include heart rate and oxygen saturation. The record lacked documented evidence that a decannulation risk assessment was completed after the event per interview with Directors.

Based on medical record and policy review, staff confirmation it was determined that the medical staff failed to write orders according to hospital policy in for Patient #31


The findings include:


The Specialty Hospital of Washington-Hadley Medical Staff Rules and Regulations, approved December 16, 2009, Part E - Treatment, Item 1 entitled Orders stipulates " b. The Practitioner ' s orders must be written clearly, legibly, and completely ... Orders must be specific. "


Policy # S.10.02, entitled Behavior Management for Non-Violent/No-Self Destructive Patients Requiring Physical Restraints/Seclusion revised July 2010, stipulates Item five (5) Duration of physician verbal and written orders for use of restraints in Long Term Acute Care medical/surgical care is time limited to 24 hours for patient. After original expires, the LIP must reassess the patient before issuing a new order ... "

Patient #31 was admitted on February 2, 2011 with diagnoses of Seizures/Epilepsy, Acute Respiratory Failure status post tracheostomy, Pneumonia Feeding Dysfunction, history of Vagus Nerve Stimulator Implant, Hypotension, Peripheral Vascular Disease, Cardiomyopathy, Encephalopathy with history of Mental Retardation, Lupus, Anemia, and Lead Intoxication. Review of the medical record starting May 24, 2012 at approximately 9:30 AM revealed the physician ordered restraints starting February 26, 2012. The medical record lacked documented evidence that the medical staff consistently ordered time limited 24 hour timeframes for restraints on February 3, 26, March 2, 3, 5, 6, 7, 9, 10, 25, 31, and April 4, 2011. The medical staff failed to write complete restraint orders per policy.

The findings were discussed with the Chief Nursing Officer (CNO) on June 7, 2012 at approximately 3:40 PM. The confirmed the findings.