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Based on review of facility documents and medical records (MR), and staff interview (EMP), it was determined that the facility failed to ensure that neurological checks were completed as per physician orders for two of three medical records. (MR11 and MR32).

Findings include:

1. During an interview on September 11, 2013, at approximately 11:10 AM, EMP2 was asked for any policies related to neurological checks. EMP2 stated, "No, there is no policy that tells nurses to follow physician orders for neuro checks..."

2. Review of MR11 on September 12, 2013, at approximately 9:30 AM revealed a physician order dated September 3, 2013, at 3:30 PM which indicated, "...neuro checks q [every] 4 hours..."

The medical record revealed that neurochecks were completed for MR11 on September 4, 2013, at 0000, and at 0400, on September 5, 2013, at 0305, 0309, and 0930, on September 6, 2013, at 0115, 0845, 1650. Neurochecks were completed for MR11 twice on September 7, and September 8, 2013.

During an interview on September 12, 2013, at approximately 10:00 AM, EMP29 confirmed that the neurological checks were not documented as per physician order.

3. Review of MR32 on September 12, 2013, at approximately 10:30 AM revealed a physician order dated September 11, 2013, at 00:40 AM which indicated, "...neuro checks q [every] 4 [hours]..."

The medical record for MR32 revealed that neurological checks were completed on September 11, 2013, at 04:41, 08:00, 14:35 and 15:50.

During an interview on September 12, 2013, at approximately 11:30 AM, EMP29 confirmed that the neurological checks were not documented as per physician order.

Based on review of facility documents and staff interview (EMP), it was determined that the facility failed to ensure that specific medication administration procedures were designated in writing.

Findings include:

Review of Medical Staff Bylaws, effective May 31, 2013, on September 12, 2013, at approximately 10:30 AM revealed, "...Article X Section 5. Division/Department chairpersons...A. Be responsible for all administrative and clinical activities within his/her division/department, particularly for the continuing surveillance of the professional performance of individuals in the department who have delineated clinical privileges; J. Develop and implement policies and procedures that guide and support the provision of services..."

1. During an interview on September 10, 2013, at approximately 11:45 AM EMP4 was asked if there were any specific policies for respiratory treatments and EMP4 stated, "No, we do not have an specific policies regarding respiratory treatments. We just have the Directions Dictionary which is not specific for any respiratory medications or treatments.

2. During an interview on September 11, 2013, at approximately 11:10 AM, EMP2 was asked if there were any specific policies for respiratory medications/treatments and EMP2 stated, "No, we do not have a specific policy regarding respiratory treatments. They follow the big one [Medication Policy]."

3. During an interview on September 11, 2013, at approximately 12:00 PM, EMP26 indicated that the inconsistent respiratory times have not been caught during record review. EMP26 further indicated, "...We just look at the number of times that the medications were given. If the medication is QID we check to see that it was given four times a day, but we haven't looked at what times the medications were given...there have not been any occurrence reports given to me for missed or late respiratory medications..."

Cross Reference with:

482.57(b)(4) Respiratory Services

Based on review of facility documents and medical records (MR) and staff interview (EMP), it was determined that the facility failed to ensure that respiratory treatments were administered as per physician orders for four of five medical records. (MR11 MR28, MR29, MR30)

Findings include:

Review of facility policy on September 12, 2013 at approximately 11:30 AM, revealed, "Medical Staff Rules and Regulations Section: Medication Administration...Medication Usage...B. Who Can Administer Medication 2. c. Respiratory therapist, radiology technicians, and nuclear medicine technicians shall only administer medication within the scope of their license/certification...5. Documentation of administration shall be completed by the administering practitioner on the appropriate record (MAR) [Medication Administration Record]...C...Medication Errors...f. If a medication was administered thirty (30) minutes or more before or after it was ordered (prn orders are not included), unless the medication was being held for a specific reason..."

Review of a facility document, "Directions Dictionary", provided by EMP4, on September 12, 2013, at approximately 12:00 PM, revealed, "...Q6H Every 6 hours 0000, 0600, 1200, 1800...QID...Four Times A Day @ 12.6.12.6...0000, 0600, 1200, 1800..."

1. Review of MR11 on September 13, 2013, at approximately 1:00 PM, revealed an order dated, September 5, 2013, which indicated "Change Duoneb to QID (four times daily), and every 2 hours PRN (as needed)." Review of the patient's medical record revealed that on September 10, 2013, the patient only received three Duoneb treatments.

During an interview on September 13, 2013, at approximately 1:25 PM EMP22, stated, "No, I only see that the patient received 3 doses on September 10, 2013.

2. Review of MR28 on September 11, 2013, at approximately 11:00 AM, revealed a physician order dated September 6, 2013, at 12:15, which indicated, "Xopenex 0.63 in 3 ML NSS Q6H [every 6 hours]..."

The Respiratory treatment record for MR28 revealed that the Xopenex treatment was given on September 9, 2013, at 02:51, a 09:05 dose was documented as refused, 13:15, 16:15, and then not again until almost 12 hours later on September 10, 2013, at 04:23.

3. Review of MR29 on September 11, 2013, at approximately 10:00 AM revealed a physician order dated September 8, 2013, at 02:09 which indicated, "Duoneb QID [four times a day] and Q2 [every 2 hours] PRN [as needed]."

The Respiratory treatment record for MR29 revealed that the the respiratory treatment was given on September 10, 2013, at 08:20, 12:30, and 16:05, and then not again until 03:24 on September 11, 2013.

4. Review of MR30 on September 11, 2013, at approximately 11:10 AM revealed a physician order dated September 6, 2013, at 12:10 PM, which indicated, "Duoneb q 4 [every 4 hours] hours PRN [as needed] for wheezing. The respiratory order was changed on September 8, 2013, at 14:10 to "Duoneb change to QID [four times a day]."

The Respiratory treatment record for MR30 revealed that the respiratory treatment was given on September 9, 2013, at 05:27, 11:30, 14:25, 18:15, and not again until 06:03 on September 10, 2013, almost 12 hours later.

During an interview on September 10, 2013, at approximately 11:45 AM, EMP4 was presented the information related MR28, and was asked is it ever appropriate for a therapist to give the treatments, every 3-4 hours instead of every 6 hours, EMP indicated, "No that is not right..."

During an interview on September 10, 2013, at approximately 2:30 PM, EMP27 indicated, "Sometimes when I am all alone, that is how we give the medication, and no, we do not document in the MAR, we document under therapy notes the medications that are administered..." EMP27 confirmed the findings for MR28 at that time.

On September 13, 2013, at 1:25 PM EMP22, stated, No, I only see the three doses given [MR29] on September 10, 2013. EMP22 confirmed the findings for MR30 at this time.


Cross Reference with:

482.57(b)(1) Respiratory Care Personnel Policies