HospitalInspections.org

Based on staff interview, review of two out of two medical records (Patient #1, #2) of patients using specialty beds, and review of facility policy and procedure, it was determined that the facility failed to ensure that specialty percussive beds are utilized in accordance with physician's orders.

Findings include:

Facility policy titled, "Nursing Documentation," (rev 4/2022), states, "...Key Points: ...Document all interventions and reassessment of the interventions and any observable changes in the patient's general condition, his symptoms and behavior, and ongoing evaluation of the current status of the patient. ..."

On 2/14/24 at 10:37 AM, during a tour of the 5 North Unit, in the presence of Staff (S)5 (5 North Assistant Nurse Manager), an interview was conducted with S8, a Registered Nurse (RN), outside of Patient (P) 2's room. S8 stated that P2 was using a bed for "percussive therapy." When asked how often the bed was utilized for the patient, he/she stated there was "no order for the frequency. It's used as needed."

At 2:45 PM, a review of P2's medical record was conducted with S2 (Quality Improvement Specialist) in the presence of S3 (Director of Patient Care Services), S4 (5 North Nurse Manager) and S5 (5 North Assistant Nurse Manager). A physician order, dated 1/26/24 stated, "Therapeutic Bed Settings...Comments: Use for percussion for 15 minutes every 2 hours." Upon review, there was no documentation found in the medical record for the use of the percussion therapy bed in accordance with physician orders. At 3:08 PM, S6 (Nurse Educator) confirmed that there was no designated location in the medical record for nursing staff to document on the frequency and use of percussion therapy for percussion therapy beds. These findings were confirmed at the time of discovery.

Upon review of P1's medical record, the following was revealed: A physician order, dated 12/18/23 at 10:11 AM for, "Chest Physiotherapy (CPT)...Comments: With TheraBed 4 x [four times] daily for 20 minutes per session." The medical record lacked documentation of the use of the percussion therapy bed in accordance with physician orders. These findings were confirmed by S2, S3, S4, and S5 upon discovery.