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The hospital failed to develop, implement and maintain an effective data driven quality assessment and performance improvement program for the Department of Respiratory Care in order to improve patient health outcomes. The Respiratory Department lacked evidence of its integration with the hospital wide quality program.

Refer to A 267.

Based on a review of facility documentation and interviews, the hospital failed to ensure that quality data was collected to assess quality care provided by the Respiratory Department. The finding includes:


a. Review of the Department of Respiratory Care Quarterly Compliance Report meeting minutes, from 4/15/11 to 1/18/12, identified that quality data including accurate pulmonary charges, complete labeling of respiratory specimens, reporting of critical Arterial Blood Gas (ABG) specimen's and scan patient identification badge prior to medication administration were compiled.

Review of the Clinical Processes Improvement Committee, CPIC, meeting minutes, from 1/21/11 to 12/8/11, failed to reflect documentation that any quality data from the Respiratory Therapy Department was reported.

Interview with the Clinical Manager of Respiratory Therapy and the Administrative Director of Respiratory Therapy, on 2/10/12 at 3:37 P.M., identified that the quality data from the Respiratory Therapy Department was not reported to the Hospital quality committee, CPIC.


During the onsite visits, the hospital failed to ensure that physician/provider orders for invasive and/or non-invasive ventilation and/or weaning from ventilators included all elements of a physician's order and/or that Respiratory Therapy staff contacted the physician for clarification of incomplete orders prior to implementing care, and/or that pulse oximeter monitors had alarm parameters set in accordance with the physician's order and/or that staffing was adequate to meet the needs of the patients.


Please cross reference A-1151.

The hospital failed to ensure that physician/provider orders for invasive and/or non-invasive ventilation and/or weaning from ventilators included all elements of a physician's order and/or that Respiratory Therapy staff contacted the physician for clarification of incomplete orders prior to implementing care, and/or that pulse oximeter monitors had alarm parameters set in accordance with the physician's order and/or that staffing was adequate to meet the needs of the patients.

Refer to A-1161, A-1154, and A-1163.

Based on review of clinical records, review of hospital documentation, policies, and interviews, for five (5) of forty six (46) patient's reviewed for respiratory services (#58, 59, 60, 61, and 86) the hospital failed to ensure that the patient's needs were met in accordance with the physician's order. The findings include:


a. Patient #58 was admitted on 1/30/12 with respiratory distress. Review of the physician orders, dated 2/8/12 at 11:10 A.M., directed that the patient be weaned from full invasive ventilatory support to a tracheostomy (trach) mask trial be completed with 40% oxygen by respiratory therapy. Review of the Respiratory Therapy notes, dated 2/8/12 at 12:35 P.M., with the Clinical Manager of Respiratory Therapy identified that the trach mask trial was not completed due to the patient's level of agitation and/or elevated heart rate. Review of the clinical record failed to reflect documentation by the Respiratory Therapist that the medical provider was informed that the trach mask trial was not completed.


b. Review of Patient #58's clinical record, with the Clinical Manager of Respiratory Therapy, dated 2/9/12 during the period of 11:11A.M. to 4:39 P.M., failed to reflect that a Respiratory Therapist assessed the patient every three hours when maintained in the CPAP mode in accordance with hospital policy. Review of the patient's ventilator, on 2/9/12 at 4:00 P.M. with the Clinical Manager of Respiratory Therapy, identified that the patient was on CPAP mode, PS of 5 cm of water, PEEP of 5 cm of water and oxygen of 40%. Interview with the Clinical Manager of Respiratory Therapy, on 2/14/12 at 8:30 A.M., identified that for a patient being ventilated exclusively in a spontaneous mode, as CPAP, the practice is that the Respiratory Therapist monitors the patient every four hours.


c. Patient #58 had a physician order, dated 2/10/12 at 8:56 A.M., which directed Respiratory Therapy to place the patient on a trach mask with 40% oxygen for one (1) hour. Review of the clinical record with the Clinical Manager of Respiratory Therapy, failed to reflect documentation that a Respiratory Therapist placed the patient on the trach mask. Interview with Respiratory Therapist #1, on 2/10/12 at 12:05 P.M., identified that he/she did not complete the trach mask trial for Patient #58 and did not inform the physician/provider that the trach mask trail was not completed.


d. Patient #59 was admitted on 1/24/12 with acute hypoxic respiratory failure. Review of the Respiratory Therapy Ventilator Settings document, dated 2/9/12 from 11:30 A.M. to 2:59 P.M., with the Clinical Manager of Respiratory Therapy identified that the patient was placed on CPAP mode with PS of 10 cm water and PEEP of 5 cm water and oxygen at 40 % absent of a physician's order. During this same period of time, the record lacked evidence that a Respiratory Therapist assessed the patient every three hours in accordance with hospital policy. Interview with the Clinical Manager of Respiratory Therapy, on 2/9/12 at 4:13 P.M., identified that there was no physician order for that intervention.



e. Patient #60 was admitted on 2/3/12 with a hemorrhagic stroke. Review of a physician order, dated 2/8/12 at 1:00 P.M., with the Clinical Manager of Respiratory Therapy directed the Respiratory Therapist to extubated the patient to room air on 2/9/12 at 8:00 A.M. Review of the Respiratory Therapy Ventilator Settings document, dated 2/9/12, identified that the Respiratory Therapist extubated the patient to room air at 9:30 A.M. The Respiratory Therapist failed to notify the physician regarding a delay in extubation.




f. Patient #61 was admitted on 1/30/12 with respiratory distress. Review of the clinical record with the Clinical Manager of Respiratory Therapy identified a physician order, dated 2/8/12 at 7:50 A.M., which directed Respiratory Therapy staff to place the patient on BIPAP non-invasive ventilation with settings of IPAP of 15 centimeters (cm) of water and EPAP of 7 cm of water at 9:00 P.M. and remove at 6:00 A.M. Although the order failed to include all elements of a physician's order (mode of ventilation, the backup respiratory rate and/or the amount of oxygen to be administered), review of the BIPAP Settings document, during the period of 2/9/12 at 1:02 A.M. to 4:30 A.M., identified that the Respiratory Therapist placed Patient #61 on BIPAP at 1:02 A.M. with the following settings Mode: spontaneous timed, IPAP of 15 cm of water, EPAP of 7 cm of water, back up rate of 10 breaths per minute and oxygen of 3 Liters per minute. At 4:30 A.M. documentation failed to reflect a backup respiratory rate. The Respiratory Therapist failed to document when Patient #61 was removed from the BIPAP.

Interview with the Clinical Manager of Respiratory Therapy, on 2/9/12 at 4:45 P.M., identified that the BIPAP orders for Patient #61 failed to include the mode of ventilation, the backup respiratory rate and the oxygen to be administered. Additionally documentation identified that the patient was "on BIPAP at 1:02 AM", although the physician's order directed 9:00 PM. Documentation failed to reflect the time the patient was removed from BIPAP.


g. Patient #86 was admitted on 2/9/12 with respiratory distress. Review of a physician order, dated 2/10/12 at 6:41 A.M., with the Clinical Manager of Respiratory Therapy directed the Respiratory Therapist to place the patient on CPAP with a Pressure Support of 10 centimeters (cm) of water, PEEP of 5 cm of water, oxygen at 40 % at 7:30 A.M. Review of the clinical record, failed to reflect documentation by the Respiratory Therapist as when the patient was placed on CPAP. Interview with Respiratory Therapist #1, on 2/10/12 at 11:10 A.M., identified that he/she supervised while Respiratory Therapy Student #1 placed Patient #86 on CPAP at 8:15 A.M. and he/she did not inform the physician/provider that the CPAP trial was started 45 minutes late.


h. Review of a physician order for Patient #86, dated 2/10/12 at 9:45 A.M., with the Clinical Manager of Respiratory Therapy that directed Respiratory Therapy to extubate the patient and place him/her on oxygen via nasal cannula at 2 Liters per minute to maintain oxygen saturation greater than 92 %. Review of the Critical Care Flowsheet, dated 10:35 A.M., identified that the patient was placed on a nasal cannula at 2 Liters per minute. Review of the clinical record, failed to reflect documentation by the Respiratory Therapist as to when the patient was extubated and placed on oxygen via nasal cannula. Interview with Respiratory Therapist #1, on 2/10/12 at 11:10 A.M., identified that he/she supervised while Respiratory Therapy Student #1 extubated Patient #86 at 10:25 A.M. and placed him/her on oxygen via nasal cannula at 2 Liter per minute.



Review of the policy and procedure, titled Respiratory Care Priorities, identified the physician will be notified when the ordered treatments cannot be completed.

Review of the policy and procedure, titled Ventilator Monitoring, Critical Care Unit, identified that any patient that is being ventilated exclusively in a spontaneous mode, as CPAP, must be monitored by the Respiratory Therapist at least every three hours and that monitoring is to be documented.

Based on review of clinical records, review of hospital documentation and interviews for two of two patients (# 86 and 87) that were extubated and required supplemental oxygen, the hospital failed to ensure that that pulse oximeter monitors had alarm parameters set in accordance with the physician's order by the staff members. The findings include:

a. Patient #86 was admitted on 2/9/12 with respiratory distress. Review of a physician order for Patient #86 with the Clinical Manager of Respiratory Therapy, dated 2/10/12 at 9:45 A.M., that directed Respiratory Therapy to extubate the patient and place him/her on oxygen via nasal cannula at 2 Liters per minute to maintain oxygen saturation greater than 92 %. Observation of Patient #86, with RN #7 and RT #1 on 2/10/12 at 11:30 A.M., identified that he/she was extubated and had oxygen via nasal cannula at 2 Liter per minute. Upon inquiry while at Patient #86's bedside, RT #1 was unable to demonstrate if the oxygen saturation parameters, via the bedside pulse oximeter monitor, were accurately set and/or if the monitor alarms were set and/or in working order. RN #7 demonstrated that the oxygen saturation parameters, via the pulse oximeter monitor, alarms were on, in working order although the parameters were not set in accordance with the physician orders (the low saturation alarm was set at 90%). RN #7 subsequently adjusted the low oxygen saturation alarm parameter to 92 % as per physician order.
b. Patient #87 was admitted on 2/4/12 with respiratory distress. Patient #87 had a physician order, dated 2/10/12 at 8:00 A.M., that directed Respiratory therapy to place the patient on a venti-mask at 40 % oxygen in order to maintain his/her oxygen saturation greater than 92 %. Review of the clinical record with the Clinical Manager of Respiratory Therapy failed to reflect documentation as to when the Respiratory Therapist implemented this directive. Observation of Patient #87, on 2/10/12 at 12:40 P.M. with RN #7 and RN #10, identified that the oxygen saturation parameters, via the pulse oximeter monitor, alarms were on; in working order although the parameters were not set in accordance with the physician orders (the low saturation alarm was set at 90%). RN #10 subsequently adjusted the low oxygen saturation alarm parameter to 92 % per physician order.



Interview with the Clinical Manager of Respiratory Therapy, on 2/10/12 at 11:45 A.M., identified that the respiratory therapists are not educated on the bedside monitor. Review of RT #1's personnel file failed to reflect documentation that he/she was educated on the bedside monitor system in the past 2 years.




According to the American Association for Respiratory Care (AARC), the Respiratory Therapist must ensure that pulse oximeter alarms are appropriately set.

Based on review of clinical records, observations of care, review of facility policies and procedures, review of facility documentation and interviews for eleven (11) of forty six (46) patient's reviewed for respiratory services (Patients #53, 58, 59, 61, 81, 83, 85, 87, 88, 93 and 94), the hospital failed to ensure that physician/provider orders for invasive and/or non-invasive ventilation and/or weaning from ventilators included all elements of a physician's order and/or that Respiratory Therapy staff contacted the physician for clarification of incomplete orders prior to implementing care and/or that pulse oximeter monitors had alarm parameters set in accordance with the physician's order. The findings include:


a. Patient #53 was admitted to the hospital on 1/24/12 for a cervical fusion. Review of the progress notes dated 2/7/12 identified that the patient had difficulty breathing with a heart rate of 150-160, blood pressure of 220/110 and oxygen saturation levels of 98%. Further review identified that anesthesia was called and the patient was re-intubated and placed on the ventilator. Although the progress notes dated 2/7/12 identified the patients ventilator settings, a review of the physician orders dated 2/7/12-2/8/12 failed to identify that an order for ventilator settings was completed for two days. Interview with the Clinical Coordinator on 2/9/12 identified that there was no order when the patient was placed back on the ventilator.

b. Patient #58 was admitted on 1/30/12 with respiratory distress. Review of a physician order, dated 2/9/12 at 8:30 A.M., directed Respiratory Therapy staff to complete a Continuous Positive Airway Pressure (CPAP) trial, while on the ventilator, with Pressure Support (PS) of 5 centimeters (cm) of water and Positive End Expiratory Pressure (PEEP) of 5 cm of water, however failed to direct the oxygen percentage. Review of the Respiratory Therapy Ventilator Settings document, dated 2/9/12 at 8:35 A.M., with the Clinical Manager of Respiratory Therapy identified that the patient was placed on CPAP with PS of 5 cm water and PEEP of 5 cm water and oxygen of 40% administered. The clinical record failed to reflect documentation that the Respiratory Therapist requested clarification regarding the physician order and/or communication with the physician.

c. Patient #58 had a physician order, dated 2/9/12 at 11:00 A.M., which directed a trach mask trial be completed with 40% oxygen by respiratory therapy. Review of the Respiratory Therapy Ventilator Settings document, dated 2/9/12 at 11:10 A.M., identified that the patient was placed on a trach mask then became restless with an increased respiratory rate and began coughing bloody sputum. The physician was notified and the patient was placed back on the ventilator in a CPAP mode. Review of the clinical record with the Clinical Manager of Respiratory Therapy failed to reflect a physician's order that directed mode of ventilation, the Pressure Support (PS), the PEEP, and/or the oxygen percentage to be administered. Review of the Respiratory Therapy Ventilator Settings document, dated 2/9/12 from 11:11A.M. to 4:39 P.M., failed to reflect documentation of the ventilator settings that the Patient was placed on. Review of the patient's ventilator, on 2/9/12 at 4:00 P.M. with the Clinical Manager of Respiratory Therapy, identified that the patient was on CPAP mode, PS of 5 cm of water, PEEP of 5 cm of water and oxygen of 40% absent of a physician's order.


d. Patient #59 was admitted on 1/24/12 with acute hypoxic respiratory failure. Review of the Respiratory Therapy Ventilator Settings document, dated 2/9/12 from 11:30 A.M. to 2:59 P.M., identified that the patient was placed on CPAP mode with PS of 10 cm water and PEEP of 5 cm water and oxygen at 40 % absent a physician's order. Review of the clinical record with the Clinical Manager of Respiratory Therapy failed to reflect that the physician was notified for ventilator support parameters.


e. Patient #61 was admitted on 1/30/12 with respiratory distress. Review of the physician orders, dated 2/7/12 at 10:40 P.M., directed the Respiratory Therapy staff to place the patient on Bi-level Positive Airway Pressure (BIPAP) non-invasive ventilation with settings of inspiratory positive airway pressure (IPAP) of 15 centimeters (cm) of water and expiratory positive airway pressure (EPAP) of 7 cm of water. The order failed to include the mode of ventilation, the backup respiratory rate and/or the amount of oxygen to be administered. Review of the Respiratory Therapy BIPAP Settings document, dated from 2/8/12 at 12:30 A.M. to 6:00 A.M., identified that the Respiratory Therapist placed Patient #61 on BIPAP at 12:30 A.M. with the following settings Mode absent of a physician's order: spontaneous timed, IPAP 15 cm of water, EPAP of 7 cm of water, back up rate of 12 breaths per minute and oxygen of 3 Liters per minute. Review of the clinical record with the Clinical Manager of Respiratory Therapy failed to reflect that physician orders were clarified.

f. Patient #61 had a physician order, dated 2/8/12 at 7:50 A.M., which directed Respiratory Therapy staff to place the patient on BIPAP non-invasive ventilation with settings of IPAP of 15 centimeters (cm) of water and EPAP of 7 cm of water at 9:00 P.M. and remove at 6:00 A.M. The order failed to include the mode of ventilation, the backup respiratory rate and/or the amount of oxygen to be administered. The Respiratory Therapist failed to contact the physician for complete orders.

g. Review of the BIPAP Settings document, during the period of 2/9/12 at 1:02 A.M. to 4:30 A.M., identified that the Respiratory Therapist placed Patient #61 on BIPAP at 1:02 A.M. with the following settings Mode absent of a physician's order: spontaneous timed, IPAP 15 cm of water, EPAP of 7 cm of water, back up rate of 10 breaths per minute and oxygen of 3 Liters per minute. At 4:30 A.M. Documentation failed to reflect a backup respiratory rate. The Respiratory Therapist failed to document when Patient #61 was removed from the BIPAP.

Review of the clinical record and Interview with the Clinical Manager of Respiratory Therapy, on 2/9/12 at 4:45 P.M., identified that BIPAP orders for Patient #61 failed to include the mode of ventilation, the backup respiratory rate, and the oxygen to be administered.


h. Patient #81 was admitted to the facility on 2/3/12 at twenty nine weeks gestation with a diagnosis of respiratory distress syndrome. Initially Patient #81 was invasively ventilated mechanically via an endotracheal tube and was eventually weaned to CPAP. On 2/9/12 at 8:45 AM Patient #81 was placed on nasal CPAP. On 2/9/12 an order was written for nasal CPAP by a physician's assistant (PA). Interview with MD #5 on 2/10/11 at 11:00 AM identified that a neonatologist should have written the order for ventilation in accordance with hospital policy. Review of the Mechanical Ventilation policy for Newborns directed that ventilator settings are ordered by the neonatologist and should include mode, amount of oxygen to be administered, and amount of pressure.

i. Review of Patient #81's respiratory flow sheets dated 2/9/12 at 8:45 AM through 2/10/12 at 8:15 AM identified that CPAP settings including oxygen administration were not documented on four occasions every two (2) hours in accordance with the hospital policy. Interview with Respiratory Therapist #1 on 2/10/12 at 11:30 AM identified that the respiratory therapist should have evaluated and documented the CPAP settings every two hours and documentation failed to reflect the settings. The hospital policy for infant ventilation and administration of CPAP directed in part that CPAP settings are to be documented every two hours including the amount of oxygen that is administered to the infant.

j. Patient #83 was admitted on 1/25/12 with weakness and Congestive Heart Failure exacerbation, worsening right sided heart failure and chronic hypercapnic hypoxic respiratory failure. Review of the physician orders, dated 2/9/12 at 9:40 P.M., directed the Respiratory Therapy staff to place the patient on BIPAP non-invasive ventilation with settings of inspiratory positive airway pressure (IPAP) of 17 centimeters (cm) of water and expiratory positive airway pressure (EPAP) of 5 cm of water, 60 % oxygen and a backup respiratory rate of 12 breaths per minute. Review of the Respiratory Therapy BIPAP Settings document, during the period of 2/9/12 at 9:00 P.M. to 2/10/12 at 12:36 A.M., identified Patient #61 was on BIPAP as per physician order. A physician order, dated 2/10/12 at 2:00 A.M., to transfer Patient #83 to the Critical Care Unit on BIPAP at the current settings. Review of the Critical Care Flowsheet, dated 2/10/12 at 3:00 A.M., with the Clinical Manager of Respiratory Therapy identified that Patient #83 was placed on a Non-Rebreather mask with fifteen (15) Liters of oxygen absent of a physician order. Review of a physician progress note, dated 2/10/12 at 4:00 A.M., identified that the patient was transferred to the Critical Care Unit on a Non-Rebreather mask even though that same physician wrote a specific order to transfer the patient on BIPAP. The clinical record failed to reflect that the Respiratory Therapist followed the physician order.

Patient #83 was intubated on 2/10/12 at approximately 4:00 A.M. and placed on invasive ventilation.

k. Patient #85 was admitted on 2/9/12 for pneumonia with hypoxia and hypertension. Review of the physician orders, dated 2/9/12 at 11:47 A.M., directed oxygen via nasal cannula in order to keep the oxygen saturation between 90-92%. Review of the clinical record, dated 2/9/12 at 2:53 P.M., with the Clinical Manager of Respiratory Therapy identified that the patient was on a Non-Rebreather mask with ten (10) Liters of oxygen, and at 5:44 P.M. a Venti-mask with twelve Liters (or 50%) of oxygen absent of physician orders. The clinical record failed to reflect that the Respiratory Therapist and/or a nursing staff member contacted the physician for oxygen orders to maintain saturation between 90-92%.

l. Patient #85 had a physician order, dated 2/9/12 at 7:00 P.M., which directed staff to transfer the patient to the Critical Care Unit on a Venti-mask with oxygen at 50%. An order, dated 2/9/12 at 9:45 P.M., directed the Respiratory Therapy staff to place the patient on BIPAP non-invasive ventilation with settings of IPAP of 12 cm of water and EPAP of 5 cm of water, with a backup rate of 14 breaths per minute and 10 Liters of oxygen. Review of the Respiratory Therapy BIPAP Settings document, dated 2/10/12 at 5:30 A.M., identified that Patient #85 was on BIPAP with the following settings Mode: spontaneous timed, IPAP 12 cm of water, EPAP of 5 cm of water, back up rate of 14 breaths per minute and oxygen of 15 Liters per minute. The clinical record failed to reflect a physician order for oxygen at 15 Liters. Review of the patient's non-invasive ventilator, on 2/10/12 at 10:35 A.M. with Respiratory Therapist #2 identified that the patient was on BIPAP with the following settings Mode: spontaneous timed, IPAP12 cm of water, EPAP of 5 cm of water, back up rate of 14 breaths per minute and oxygen of 10 Liters per minute. Interview with Respiratory Therapist #1, on 2/10/12 at 11:10 A.M., and review of his/her 5:30 A.M. documentation, identified that Patient #85 was on fifteen Liters of oxygen and maybe that is a documentation error.

m. Patient #87 was admitted on 2/4/12 with respiratory distress. A physician order, dated 2/9/12 at 5:30 P.M., directed the Respiratory Therapy staff to place the patient on BIPAP non-invasive ventilation with settings of IPAP of 15 centimeters (cm) of water and EPAP of 5 cm of water at hour of sleep with 10 Liter per minute of oxygen. The order failed to include the mode of ventilation and/or the backup respiratory rate. Review of the Respiratory Therapy BIPAP Settings document, dated 2/9/12 at 10:40 P.M., with the Clinical Manager of Respiratory Therapy identified that the Respiratory Therapist placed Patient #87 on BIPAP with the following settings Mode: spontaneous, IPAP of 15 cm of water, EPAP of 5 cm of water and oxygen of 10 Liters per minute absent a physician order for mode of ventilation and/or the backup respiratory rate.

n. Patient #87 had a physician order, dated 2/9/12 at 11:58 P.M., that directed the Respiratory Therapy staff to place the patient on BIPAP non-invasive ventilation with settings of IPAP of 15 cm of water and EPAP of 5 cm of water at hour of sleep with 15 Liter per minute of oxygen. The order failed to include the mode of ventilation and/or the backup respiratory rate. Review of the Respiratory Therapy BIPAP Settings document, dated 2/9/12 at 11:20 P.M., with the Clinical Manager of Respiratory Therapy identified that the Respiratory Therapist placed Patient #87 on BIPAP with the following settings Mode: spontaneous, IPAP15 cm of water, EPAP of 5 cm of water and oxygen of 15 Liters per minute absent a physician order for mode of ventilation and/or the backup respiratory rate.

o. Review of the Respiratory Therapy BIPAP Settings document, dated 2/10/12 at 5:35 A.M., identified that the Respiratory Therapist placed Patient #87 on BIPAP with the following settings Mode: spontaneous timed, IPAP of 15 cm of water, EPAP of 5 cm of water and oxygen of 15 Liters per minute absent a physician order for mode of ventilation. Review of the clinical record with the Clinical Manager of Respiratory Therapy failed to reflect documentation that the Respiratory Therapist contacted the physician for clarification of the order.

p. Patient #87 had a physician order, dated 2/10/12 at 8:00 A.M., that directed Respiratory therapy to place the patient on a venti-mask at 40 % oxygen in order to maintain his/her oxygen saturation greater than 92 %. Review of the clinical record with the Clinical Manager of Respiratory Therapy failed to reflect documentation as to when the Respiratory Therapist implemented this directive. Observation of Patient #87, on 2/10/12 at 12:40 P.M. with RN #7 and RN #10, identified that the oxygen saturation parameters, via the pulse oximeter monitor, alarms were on; in working order although the parameters were not set in accordance with the physician orders (the low saturation alarm was set at 90%). RN #10 subsequently adjusted the low oxygen saturation alarm parameter to 92 % per physician order.

q. Patient #87 was admitted on 2/4/12 with respiratory distress. A physician order, dated 2/12/12 at 2:10 P.M., directed the Respiratory Therapy staff to place the patient on BIPAP non-invasive ventilation with settings of IPAP of 17 centimeters (cm) of water and EPAP of 8 cm of water at hour of sleep with 60% of oxygen at 9:00 P.M. and remove at 6:00 A.M. The order failed to include the mode of ventilation and/or the backup respiratory rate. Review of the Respiratory Therapy BIPAP Settings document, dated 2/12/12 from 10:45 P.M. to 2/13/12 at 6:00 A.M., with the Clinical Manager of Respiratory Therapy identified that the Respiratory Therapist placed Patient #87 on BIPAP with the following settings Mode: spontaneous timed, IPAP of 17 cm of water, EPAP of 8 cm of water, 60 % oxygen, and a backup respiratory rate of 10 breaths per minute absent of a physician's order for the mode of ventilation and/or back up respiratory rate. The Respiratory Therapist failed to contact the physician for clarification of orders.

r. Review of Patient #87's Respiratory Therapy BIPAP Settings document, dated 2/13/12 from 10:01P.M. to 2/14/12 at 6:00 A.M., with the Clinical Manager of Respiratory Therapy identified that the Respiratory Therapist placed the Patient on BIPAP with the following settings Mode: spontaneous timed, IPAP of 15 cm of water, EPAP of 5 cm of water and oxygen of 60% and a backup respiratory rate of 10 breaths per minute absent a physician order for the mode of ventilation and/or back up respiratory rate.

s. Patient #88 was admitted on 2/8/12 with respiratory distress. Review of the physician orders, dated 2/12/12 at 11:44 A.M., directed Respiratory Therapy to decrease the oxygen administered, via the invasive mechanical ventilator, to 40 % in order to keep the oxygen saturation equal to and/or greater than 92%. If the oxygen saturation is greater than 92%, the PEEP is to be decreased to 7 centimeters (cm) of water for thirty minutes. If the oxygen saturation is greater than 92%, decrease the PEEP to 5 cm of water for thirty minutes. Review of the Respiratory Therapy Ventilator Settings document, dated 2/12/12 from 12:22 P.M. to 2:40 P.M., with the Clinical Manager of Respiratory Therapy identified that at 12:22 P.M. the oxygen was decreased to 40%. Five minutes later, at 12:27 P.M. the PEEP was decreased to 7 cm of water. At 2:40 P.M. the PEEP was decreased to 5 cm of water, two hours and eighteen minutes later although he physician order directed that the patient be maintained for thirty minutes at the previous PEEP level. Review of the Critical Care Flowsheet, dated 2/12/12 from 12:25 P.M. to 2:00 P.M., identified that Patient #88's oxygen saturation ranged between 94 to 96 %. The Respiratory Therapist failed to implement the orders as directed. Interview with MD #4 and the Medical Director of the Critical Care Unit on 2/14/12 at 9:40 A.M., identified that the Respiratory Therapist (s) did not communicate with him/her.

t. Patient #93 was admitted on 2/10/12 with acute and chronic hypoxic hypercapnic respiratory failure. Review of the physician orders, dated 2/13/12 at 10:00 A.M., directed Respiratory Therapy to place the patient on the following mechanical ventilator settings when the patient's endotracheal tube was changed: Assist Control (AC) mode with a respiratory rate of 12 breaths per minute, Tidal Volume (TV) of 500, PEEP of 5 cm of water and 100% oxygen then after the tube change place the patient on AC mode with a respiratory rate of 12 breaths per minute, TV of 500 PEEP of 5 cm of water and 50% oxygen. Review of the Respiratory Therapy Ventilator Settings document, dated 2/13/12 at 9:15 P.M., identified that the patient was on the following settings: Mode :AC, respiratory rate of 12 breaths per minute, TV of 500, PEEP of 5 cm of water and 100 % oxygen.

Review of the clinical record identified an untimed anesthesia providers' note dated 2/13/12 that reflected the patient's endotracheal tube was changed with ease.

A clinical event note, authored by RN #11 dated 2/13/12 at 9:20 P.M., identified that the patient's endotracheal tube was changed at 9:20 P.M. by anesthesia.

Review of the Respiratory Therapy Ventilator Settings document, dated 2/14/12 at 12:00 Midnight, identified in part that the patient was on the 50 % oxygen. The clinical record failed to reflect documentation when the Respiratory Therapist titrated the oxygen from 100% to 50% per physician order. Chart review and interview with the Clinical Manager of Respiratory Therapy, on 2/14/12 at 8:47 A.M., was unable to identify when the Respiratory Therapist, after the endotracheal tube change, adjusted the oxygen level in accordance with the physician order.

u. Patient #94 was admitted on 2/13/12 with acute dyspnea. A physician order, dated 2/13/12 at 11:55 A.M., directed the Respiratory Therapy staff to place the patient on CPAP non-invasive ventilation with Pressure Support (PS) of 7 cm of water and 2 Liters of oxygen at hour of sleep. Review of the Respiratory Therapy Settings document, dated 2/14/12 from 12:20 A.M. to 6:05 A.M., with the Clinical Manager of Respiratory Therapy identified that the Respiratory Therapist placed Patient #94 on CPAP with the following settings PS of 7 cm of water and oxygen of 2 Liters per minute. On 2/14/12 at 6:06 A.M., Respiratory Therapist #4 removed Patient #94 from the CPAP despite no physician order for this intervention.


Review of the policy and procedure, titled BIPAP/NPPV, identified that the physician order must contain the mode of ventilation (and with the spontaneous timed mode, the backup respiratory rate must be ordered), the IPAP, the EPAP and the oxygen to be administered or target oxygen saturation.

Review of the policy and procedure, titled Charting Orders, identified that when an order is incomplete the order will be clarified.

Review of the Medical Staff Bylaws Rules and Regulations, dated 1/18/11, identified that orders that are incomplete will not be carried out and licensed respiratory therapists may accept and transcribe telephone orders for respiratory care from medical providers.

Review of the facility policy and procedure, titled Ventilator , Check after Changes, identified that if a ventilator parameter is changed, for example from one mode to another, the Respiratory Therapist must assess the patient and document the assessment and changes.

According to the American Association for Respiratory Care (AARC), the physician/provider orders must include the oxygen to be administered.