HospitalInspections.org

Based on document review, medical record (MR) review, and interview, in 1 of 3 MRs (Patient #1) nursing care documentation was lacking. Specifically, Patient #1, a bariatric surgical patient had physician orders for CPAP (Continuous Positive Airway Pressure) use post operatively. Nursing care documentation did not reveal if the patient was wearing the CPAP as ordered. This lack of documentation does not accurately portray the care provided to patients and could adversely affect patient outcomes.

CPAP - A machine that helps keep the windpipe open during sleep. It delivers forced air that prevents episodes of airway collapse that block the breathing in people with obstructive sleep apnea (OSA) and other breathing problems. It delivers a constant level of air.

BiPAP / Bilevel (bilevel positive airway pressure) - A machine that helps keep the windpipe open during sleep. BiPAP machine is used to treat sleep apnea and other conditions. It delivers air at two different pressure levels, one for breathing in and one for breathing out.

Findings include:

-- Review of the hospital's policy and procedure (P&P) titled "Respiratory Therapy: CPAP/Bilevel for Sleep," last reviewed/revised 8/2021, indicated patients are allowed to bring their home CPAP to the hospital. All home units brought into the hospital must be assessed for cleanliness and proper functioning thru Clinical Engineering. In the event the patient does not have their own equipment, nursing will place an order for "QHS (every bedtime) CPAP" that will alert Agiliti, (the hospital's equipment supply department) to deliver the equipment to the patient's room. Respiratory Therapy (RT) will receive a requisition with the order for CPAP and will deliver soft goods, fit patient for mask, and setup for patient use. All patients on CPAP/Bilevel for sleep will been seen by RT each night to assess usage of equipment and need for assistance.

-- Review of nursing education provided at the time of hire titled "Caring for the Bariatric Surgery Patient," undated, indicated the most challenging aspects of caring for patients with obesity (not just surgical) are management of pulmonary complications. They have difficulty taking a deep breath to fully expand the lungs. Obese patients desaturate twice as quickly as normal weight individuals. Respiratory considerations include: CPAP as ordered; continue on arrival to floor during hours of sleep and when napping. CPAP ordered for everyone due to undiagnosed sleep apnea being a leading cause of death in obese patients. Apply O2 (oxygen) NC (nasal cannula) then titrate per oxygen protocol.

-- Per MR review, Patient #1 was admitted on 5/4/2021 for elective bariatric surgery on the same day. The patient had a history (not exclusive) of morbid obesity, high blood pressure, diabetes, high cholesterol, and sleep apnea.

A preoperative "Patient Belongings/Valuables" list indicated she brought her medical device (CPAP) with her.

Bariatric surgery was performed at 2:52 pm and it was noted that the patient tolerated the procedure well.

Physician post operative orders included oxygen via nasal cannula, routine continuous to keep sats (oxygen saturation [SpO2]) > 92%. Call MD if patient needs > 4 liters/minute of oxygen. CPAP routine continuous. Initiate in PACU (post anesthesia care unit) and continue on arrival to floor during hours of sleep and napping.

From the Operating Room (OR) Patient #1 went to the PACU and at 7:05 pm, nursing documented O2 device - nasal cannula at 3L (liters)/minute, CPAP d'cd (discontinued).

She was admitted to the inpatient unit at approximately 7:45 pm.

Nursing documented on 5/4/2021
-7:46 pm - O2 at 3L/minute via nasal cannula, SpO2 = 96%
-9:14 pm - O2 at 3L/minute via nasal cannula, SpO2 = not listed
-11:33 pm - O2 at 3L/minute via nasal cannula, SpO2 = 97%

Nursing documented on 5/5/2021
- 12:06 am - O2 at 3L/minute via nasal cannula, SpO2 = not listed
- 3:15 am - O2 at 3L/minute via nasal cannula, SpO2 = 97%

Respiratory Therapy documented on 5/5/2021
- 3:50 am - O2 device: CPAP

Nursing documented on 5/5/2021
- 9:07 am - O2 at 2L/minute via nasal cannula, SpO2 = 95%

Physician Assistant documented (in part) on 5/5/2021
- 9:09 am - (Postoperative) Patient is starting to feel better. Did not feel well late yesterday or overnight. Pain is controlled. Denies nausea/vomiting. Is not ambulating adequately. Patient denies shortness of breath, chest pain, or calf pain. Heart is regular. Lungs are clear. Abdomen is soft. Not passing flatus. Surgical site is closed. No drainage or redness. Ambulating to bathroom but not in the halls, encouraged her to try this morning. Voiding spontaneously. Will check on her later but suspect she will likely stay in house until tomorrow, Sleep apnea: Plan - CPAP QHS. Oxygen dependent: Plan - 2L at baseline during the day and 5L at night.

Nursing documented on 5/5/2021
- 11:54 am - SpO2 = 96%.

Surgeon documented (in part) on 5/5/2021
- 1:55 pm - Working with OT/PT (occupational therapy/physical therapy) to get OOB (out of bed). Had two episodes of near fall due to legs feeling weak. Good oral fluid intake. Continue post-op care. Not yet ready for discharge.

Nursing documented on 5/5/2021
- 3:19 pm - O2 at 3L/minute via nasal cannula, SpO2 = 100%
- 3:40 pm -request to Agiliti for "personal fan, CPAP machine please"

Nursing documented on 5/5/2021
- 8:29 pm - O2 at 2L/minute via nasal cannula, SpO2 = 95%
- 10:02 pm - O2 at 2L/minute via nasal cannula, SpO2 = not listed

Surgeon ordered on 5/5/2021
- 10:24 pm - CPAP, routine continuous until specified. Needs hospital machine.

Nursing documented on 5/5/2021
- 10:29 pm and 10:31 pm - request to Agiliti for "Dreamstation CPAP Auto w/Humid"
- 11:12 pm - SpO2 = 95%

Nursing documented on 5/6/2021
- 2:49 am - CPAP

Respiratory Therapy documented on 5/6/2021
- 2:47 am and 2:49 am - HS (bedtime) - CPAP, checked by RT, mask type/size - nasal, medium, settings checked, skin was intact, humidified O2 2L via nasal, CPAP - hospital machine.

Nursing documented on 5/6/2021
- 3:11 am - O2, vital signs, SpO2 = 95 %.
- 5:23 am - patient found in bed by staff, last seen alive at 3:11 am, pulseless, unconscious, apneic. CPR (cardiopulmonary resuscitation) started.

Provider documented (in part) on 5/6/2021
- 6:05 am - patient found without a pulse and unresponsive with CPAP off. Her last know well time was approximately 3:30 am. A code was called. CPR done and medications administered. Patient intubated by anesthesia. She had return of spontaneous circulation. She was transferred to intensive care unit (ICU). Suspect aspiration with OSA.

Provider documented (in part) on 5/6/2021
- 7:51 am - responded to Code. In summary patient was found in pulseless electrical activity (PEA) with her oxygen off (patient is O2 dependent and had been on CPAP). Suspect this was primary respiratory event. Will also do cardiac workup. Concern for sepsis due to aspiration. Patient had emesis on bed, around face - concern for aspiration.

Patient #1 suffered a severe irreversible brain injury. Family stated they wanted to withdraw care based on the patient's stated wishes and values and the high risk for poor neurological outcomes and survival. The patient died at 6:12 pm (5/6/2021), with family at the bedside.

-- Per interview of Staff A, Registered Nurse (RN) (provided care to Patient #1) on 7/26/2022 at 3:10 pm, at the beginning of his/her shift (5/5/2021 at 7:00 pm) the previous nurse assigned to Patient #1 said the CPAP machine had not been delivered yet, so Staff A put another order in requesting the CPAP machine and received it close to 10:30 pm - 11:00 pm. Respiratory Therapy usually sets up the CPAP, sometimes nursing sets it up. He/she revealed on 5/6/2021 at approximately 3:00 am Patient #1 had a CPAP in her room from Agiliti. At this time she was not wearing her CPAP mask. Staff A woke her up and told her to put her mask back on. At 4:00 am, Staff A went to answer the call light from Patient #1's roommate and he/she noticed Patient #1's CPAP mask was not on tight, like it was off to the side of her face. He/she questioned if he/she should wake up the patient but didn't wake her and just adjusted the mask on her face. At the time of the cardiopulmonary event he/she recalled Patient #1's CPAP was not on her face but the machine was running.

-- Per interview of Staff B, RN, (provided care to Patient #1) on 7/27/2022 at 3:20 pm, Patient #1 had a CPAP machine in the back of the room and was on oxygen. The CPAP order is noted by nursing and goes to RT and comes to the floor soon after through Agiliti, if the patient doesn't have their own machine. Agiliti can't see the CPAP order until the patient has been admitted to the inpatient room. Post operative patient education includes to use the CPAP when sleeping. He/she usually documents if the CPAP is on or off. If a patient refuses to use CPAP the physician (whoever is covering) is notified. Usually RT sets up CPAP, if it's a home machine the RN will set it up.

-- Per interview of Staff C, Nurse Manager on 7/25/2022 at 10:55 am, Gastric Bypass patients have to wear a CPAP, they are educated on why a CPAP is so important. Sometimes the patient is lethargic post operatively and may have some difficulty breathing. The surgeon orders the CPAP to what they want on the order set. If a patient is not wearing a CPAP, the provider is notified and the patient is re-educated. Patients can come to the hospital with their own CPAP machine or a CPAP order is placed through Agiliti and they deliver the machine. The order goes to RT also. Respiratory Therapy applies the CPAP, some RNs are comfortable setting up the machine but RT always comes to up to check it. Documentation of CPAP use is in the vital signs section of MR.

-- During interview of Staff D, RN on 7/25/2022 at 11:20 am, he/she revealed a patient's MR doesn't show if the patient brought in their own CPAP machine, the PACU nurse will mention it. Bariatric patients sometimes refuse to wear the CPAP, Their refusal has to be documented and the provider has to be notified. Respiratory Therapy sets up the machine and rounds to make sure the machine is in the room and used at night. Staff D doesn't set up the machine but provides education to the patient.

-- During interview of Staff E, Preoperative RN on 7/25/2022 at 2:00 pm, he/she revealed bariatric patients are told to bring their CPAP mask and tubing, not the machine to the hospital. All bariatric patients are on CPAP/BiPAP in the PACU and is setup by the PACU nurse. Preoperative nurses take inventory of a patient's belongings and would include the mask and tubing on the inventory list.

-- During interview of Staff F, Respiratory Therapy Manager on 7/25/2022 at 2:40 pm, he/she indicated RT should document when a patient refuses a CPAP, it happens quite often with bariatric patients. Respiratory Therapy does the initial set up of a CPAP machine and documents on the flowsheets under non-invasive. CPAP patients take their mask on and off. Patients bring in their own CPAP machines and should be set up by RT, not nursing. Patients bring their own mask because they fit the best.

-- During interview of Staff G, Bariatric Program Coordinator on 7/26/2022 at 2:15 pm, he/she revealed Patient #1 had a CPAP at home but is unsure if she had oxygen at home. Patient #1 had a CPAP in the hospital supplied by the hospital. Postoperatively patients are to wear the CPAP when napping and at bedtime. If a patient refuses to wear a CPAP the attending physician is notified, and the patient is monitored closely. Patients are on CPAP in PACU. When they arrive to the inpatient unit RT sets up the CPAP.

-- During interview of Staff H, RN on 7/28/2022 at 9:30 am, he/she revealed when an order is put in for a CPAP, it goes to Agiliti, who brings up the machine. Some patients bring in their own CPAP machine and it comes up to the inpatient unit with the patient. In the MR under vital signs is a drop-down box to document how may liters of oxygen and/or if the patient's CPAP is on or off.

-- Per interview of Staff I, Respiratory Therapist on 7/29/2022 at 11:30 am, requisitions for CPAP machines are received and printed in the RT office and assigned to the respiratory therapist covering that unit. The CPAP machine is delivered through Agiliti. The machine won't be delivered until the order is placed. Respiratory Therapy talks to the patient and checks to see if the patient wears a CPAP at home. He/she indicated some patients refuse to wear one. If RT arrives to the unit before Agiliti brings the equipment, RT will call Agiliti to speed up the process. Respiratory Therapy documents in the MR if the patient is wearing the CPAP mask or refusing it. If the patient refuses CPAP, RT usually notifies the nurse. Respiratory Therapy rounds once a night. If the patient is ready for bed, the respiratory therapist will assist the patient with their CPAP, if the patient is not ready for bed they will return a little later. Patients that bring in their own machine are seen by RT. Respiratory Therapy makes sure the machine is plugged in, set up and if the patient is wearing oxygen. If the patient is using a hospital machine they are asked if they know their home settings and it is set up. Patients take their mask on and off at night. Staff I explains to patients why the CPAP was ordered, what the machine does, and the benefits of wearing it. He/she tries to see patients before bedtime. If the patient is asleep, he/she wakes them up. If it's past the patients bedtime (later at night or very early morning hours) and the patient is asleep, he/she talks to the nurse about wearing the CPAP.

-- During Exit Conference on 8/4/2022 at 11:30 am, Staff J, Accreditation and Regulatory Specialist, Clinical Quality and Safety, acknowledged these findings.