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Based on observation, record review and staff interview, the facility failed to ensure post operative respiratory exercises were implemented and intakes and output were recorded as per the physician orders. This affected three (Patients #3, #4 and #5) of ten patients reviewed.

See A392.

Based on observation, record review and staff interview, the facility failed to ensure post operative respiratory exercises were implemented and intakes and output were recorded as per the physician orders. This affected three (Patients #3, #4 and #5) of ten patients reviewed.

Findings include:

1. Record review revealed Patient #4 had gastric sleeve surgery on 12/04/23 and was admitted to floor 7 K at 11:15 PM. Post-op orders were written by the surgeon at 11:18 PM to complete incentive spirometry every two hours while awake. The medical record listed lungs sounds as clear at 11:15 PM and again on 12/05/23 at 9:00 AM. No documentation was found in this medical record that the incentive spirometry was completed every two hours as ordered. The first documentation of cough and deep breathing completed was on 12/05/23 at 8:15 PM.

During an interview on 12/05/23 at 4:30 PM, Patient #4 stated surgery had been done the day prior. Patient #4 stated they had received an incentive spirometer and pointed to the device still in the bag in the room. Patient #4 stated they thought they were supposed to use the spirometer four times a day.

2. Record review revealed Patient #5 was admitted to their room on 12/04/23 at 11:48 AM after robotic surgery for a gastric sleeve. Orders were received for incentive spirometry every two hours while awake. The medical record lacked evidence of the use of the spirometer or any cough and deep breathing exercises completed.

During interview on 12/05/23 at 4:35 PM, Patient #5 stated they had surgery the day prior, received a spirometer yesterday but have not used it at all today.

3. Record review revealed Patient #3 was admitted on 09/11/23 at 5:21 AM for a scheduled cholecystectomy (gallbladder removal.) The operative notes indicated the gallbladder was removed by laparoscope with no evidence of a bile leak documented and the right upper quadrant was copiously irrigated.

Notes in the post anesthesia care unit (PACU) revealed this patient complained of severe abdominal pain with physician orders to keep overnight for pain control. Patient #3 was transferred to floor 7 K on 09/11/23 at 9:50 AM for observation. Physician orders post-op were received on 09/11/23 at 4:56 PM to encourage coughing and deep breathing, provide an incentive spirometry to use every two hours while awake, to document intake and output every eight hours and to advance to a regular diet as tolerated.

No documentation was found in this medical record that an incentive spirometer was provided or that coughing and deep breathing exercises were provided every two hours while awake. Documentation was found that 200 ml of fluid was given in the PACU but the record lacked documentation Patient #3 was given any more food or fluid during the hospital stay. Patient #3 discharged home on 09/12/23 at 9:51 AM.

Nursing assessments on 09/11/23 at 5:08 PM and 09/12/23 at 1:20 AM listed loss of appetite and nausea. Nursing notes on 09/12/23 at 7:39 AM again listed loss of appetite and no gas. The gastrointestinal care plan on 09/11/23 and 09/12/23 stated to monitor percentage of each meal consumed, administer IV fluids as ordered to ensure adequate hydration and to maintain NPO status until nausea is gone.

The medical record was reviewed with Staff A who found one entry of documentation on 09/11/23 at 8:45 PM of cough and deep breathing exercises completed, otherwise no documentation was found. Staff A further verified on 12/06/23 at 4:14 PM that there was no evidence this patient had anything to drink or eat after leaving the PACU.

During an interview on 12/07/23 at 9:50 AM, discharge nurse Staff E stated they have no recollection if this patient ate or drank anything prior to discharge. The medical record was reviewed with Staff E revealing no documentation of eating or monitoring intakes and output. Staff E stated her head to toe assessment stated loss of appetite. They generally document intakes and outputs when the meal tray is removed from the room but nothing was marked. Most likely Patient #3 was not drinking. Staff E further stated the standard of care would be to have the patient tolerate liquids without vomiting prior to discharge. Nursing notes stated the IV was taken out at 9:01 AM, the patient was given discharge instructions at 9:24 AM and discharged home at 9:51 AM.

A request was made to Staff A for a policy related to completing intakes and outputs, use of incentive spirometry and discharge criteria. Staff A stated on 12/06/23 at 4:30 PM this facility does not have a policy for these issues, that staff are to follow the physicians orders.

These findings were verified with Staff D on 12/04/23 at 4:30 PM and with Staff A and B on 12/07/23 at 1:00 PM.