HospitalInspections.org

1. Based on staff interview, medical record and documentation review of an isolated incident, it was determined that the Respiratory Therapy staff failed to document nebulizations and aerosol treatments as prescribed by the physician.

The findings include:

Patient #1 was admitted February 7, 2010 with diagnoses of Hypoxia, Respiratory Distress, Respiratory Syncytial Virus (RSV) infection, and Bronchiolitis due RSV, a history of Chronic Lung Disease (CLD) of prematurity, Pulmonary Hemosiderosis, Pulmonary Hypertension, Pulmonary Vein Stenosis, Hypothyroid, Gastro-esophageal Reflux Disease (GERD) Renal Impairment, Atrial and Ventricular Septal Defects (repaired), Fluid Imbalance related to Diarrhea, and Trisomy 21 (Down ' s Syndrome).

Review of the medical record revealed the physician ordered nebulization (NEB) treatments on February 8, 2010 at 11:25 AM as follows: " Levalbuterol (Xopenex) 0.63 mg/3ml inhalation, nebulizations every 4 hours, Routine " and budesonide (Pulmicort) 0.5 mg/2ml, Aerosol, nebulizations every 6 hours, Routine. " The medical record reflected the start date/time as February 8, 2010 at 11:25 AM.

Review of " RT-Aerosol Treatment text note, Nursing Flow sheets (I-View) entitled Pre-Treatment Assessment, Post-Treatment Assessment, Breath Sounds and the Electronic Medication Record (EMAR), revealed that a nebulizations treatment with Xopenex was administered on February 9, 2010 at 4:12 AM. The medical record lacked documented evidence that the treatment was administered as scheduled between 8:00 AM and 9:00 AM on February 9, 2010; however the RT documented an assessment at 8:00 AM on February 9, 2010. In addition there was no documented evidence of an explanation for the missed treatment.

A telephone interview was conducted with the RT on December 1, 2010 at 9:50 AM. The RT stated s/he completed the treatment, and the treatment was a scheduled treatment not PRN (whenever necessary).

The patient was intubated on February 9, 2010 between 10:00 AM and 11:00 AM and the frequencies for the nebulization/aerosol treatments were changed as follows:

February 9, 2010 at 11:27 AM, Xopenex 0.63 mg, Inhalation, NEB q 2 hr start date February 9, 2010 at 12:00, pharmacy verified, accepted the order at 12:19 PM;

February 9, 2010 at 11:28 AM Pulmicort 0.5 mg, Aerosol Neb, q 12 hr start date February 9, 2010 11:28, pharmacy verified and accepted the order 11:45 AM;

The medical record lacked documented evidence that the 2:00 PM treatment was administered.
Further review revealed that the RT documented assessments at 11:00 AM and 2:00 PM on February 9, 2010.
Review of RT treatments on February 10, 2010, revealed no documented evidence that a Xopenex treatment was administered at 4:00 AM for the q 2 hour scheduled Xopenex treatment.

2. Based on staff interview and medical record review of an isolated incident, it was determined that the Respiratory Therapy (RT) inadvertently turned off the oxygen flow meter after completion of a nebulization treatment to Patient #1. In addition the RT failed to document an episode of respiratory distress for Patient #1.

The findings include:

A telephone interview was conducted on December 1, 2010 at 9:50 AM. with the RT that was assigned to Patient #1 on February 9, 2010. The interview revealed the following: The RT stated s/he had given a respiratory treatment in the AM. " I was turning off room air but accidentally turned off the oxygen " The RT stated that s/he recognized what occurred and turned the oxygen on immediately and the patient responded well.

The RT stated it lasted a short time. The entire episode lasted five (5) minutes. The RT stated that the whole team responded (medical/nursing). The team was on the unit during that time.

The RT was questioned regarding RT ' s documentation in the medical record. The RT stated that the documentation is electronic and completed in Cerner (facility computer system). There is a task list that contains respiratory care and medication administration record (MAR) documents. Task list includes timed procedures, pre and post procedures, vital signs, breath sounds, med effect and any other activities. There is a comment section in " Ad Hoc " documentation for respiratory reports; progress reports/notes would be reflected in the respiratory reports.

The medical record lacked evidence that the RT documented the aforementioned episode of respiratory distress that occurred on February 9, 2010.