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Based on observation, record review, staff interview, and review of the facility's Policy, the facility failed to ensure the nursing respiratory assessment was being monitored and completed every 2 hours for 1 of 1 patient observed for care with an Endotracheal Tube and on a mechanical ventilation, out of 30 sampled patients. (Patient #14)


The findings include:


An observation was done on 2/27/18 at 10:15 am for Patient #14 in Room 112, Ventilator Unit. Surveyor observed Patient #14 on a mechanical ventilation and with endotracheal tube.


Record review of the medical record revealed Patient #14 was admitted to the facility on 2/22/18 with a diagnosis of Pneumonitis, Respiratory failure and history of CVA, diabetes and hypertension. He is a 63-year-old male who has an artificial airway endotracheal tube (ETT) and is on a mechanical ventilator while residing at facility.


Review of Patient #14's nursing assessments revealed that between 2/27/18 at 8:00am and 2/27/18 at 7:30pm, there were no respiratory lung field assessments performed by nursing staff.


Review of Patient #14's nursing assessments revealed that between 2/27/18 at 8:30pm and 2/28/18 at 7:00am, there were no respiratory lung field assessments performed by nursing staff.


Review of Patient #14's nursing assessments revealed that between 2/28/18 at 8:30am and 2/28/18 at 7:30pm, there were no respiratory lung field assessments performed by nursing staff.


Review of Patient #14's nursing assessments revealed that between 2/28/18 at 8:30pm and 3/1/18 at 11:00am, there were no respiratory lung field assessments performed by nursing staff.


Interview was conducted with the House Supervisor on 3/1/18 at 11:15am. He confirmed Nursing had not performed respiratory lung field reassessments after the initial shift assessment for Patient #14 on 2/27/18 to 3/1/18. He stated that nurses were supposed to assess the lung fields every 2 hours, because this Patient #14 was on mechanical ventilation and has an endotracheal tube. This Patient was the only one on the unit that had an endotracheal tube airway. He also stated that the nurse caring for Patient #14 was busy at the moment with giving medications. He explained that they will find out why the nurse had not documented her nursing assessment in the electronic medical record.


An interview was conducted with Employee J (Registered Nurse) on 3/1/18 at 2:00pm. She stated, "I'm helping everyone today and take care of Patient #14. I'm a Resource Nurse and I did not get a chance to document on the computer for my Patient #14. I documented my assessment every 2 hours on my paper. The expectation is that we assess the respiratory lung fields, to be completed every 2 hours for a Patient #14, who is on a ventilator with ETT airway. I just put my assessment in the computer now."


A review of the facility's nursing policy ID#4441867 entitled, "Care of the Patient with ET Tube" dated 1/2018 documented, " ...All patients with an ET require frequent assessment and monitoring to maintain a patent airway. A respiratory assessment completed by the primary nurse is required every two hours." The policy also listed nursing assessment procedures: "Respiratory ETT assessment and documentation is required at least every 2 hours in the electronic health record."

Based on record review and staff interview, the hospital failed to have patient discharge summary with outcome of hospitalization, disposition of care and provisions for follow-up care documented within 30 days of discharge for 3 Patients (#10, #26, #31,) out of 30 closed patient records sampled.


The findings include:


A record review was conducted for Patient # 10 which revealed a date of admission of 11/2/2017 and discharged on 12/10/2017.


A review of the physician's Discharge Summary for Patient #10 revealed a completed date of 1/30/2018 (50 days after the patient discharge) instead of the required 30 days.


An interview with the Hospital Risk Manager on 3/1/2018 at 10:30am confirmed the Discharge Summary for Patient #10 was not completed within the required 30 days of discharge.


2) A record review was conducted for Patient #26, which revealed a date of admission of 11/30/2017 and discharged on 12/16 2017.


A review of the physician's Discharge Summary for Patient #26 revealed a completed date of 1/25/2018 (39 days after discharge) instead of the required 30 days.


An interview with the Hospital Risk Manager on 2/28/2018 at 2:15 PM confirmed the Discharge Summary for Patient #26 was not completed within the required 30 days of discharge.


3) A record review was conducted for Patient #31, which revealed a date of admission of 12/12/2017 and discharged on 12/23/2017.


A review of the physician's Discharge Summary for Patient #31 revealed a completed date of 1/30/2018 (37 days after discharge) instead of the required 30 days.


An interview with the Hospital Risk Manager on 2/28/2018 at 2:30pm confirmed the Discharge Summary for Patient #31 was not completed within the required 30 days of discharge.


A review of the Hospital By-laws of the Medical staff Specialty approved in November 2016 revealed "Discharge Summary shall be dictated for all patients within 30 days of discharge."

Based on record review and staff interview, the facility failed to ensure the ventilator check was completed by Respiratory Therapy for 1 of 30 patient charts reviewed. (Patient #14)


The findings include:


The record review on 3/1/18 at 11:00 am of the electronic medical chart for Patient #14 revealed there was no ventilator checks for prescription and setting recorded by Employee I (Respiratory Therapy) as per policy on 2/28/18 at 11:51am (last ventilator check was done at 8:00am on 2/28/18) and 2/28/18 at 11:05pm (last ventilator checked done 5pm on 2/28/18).


The interview with the Director of Respiratory on 3/1/18 at 11:44am confirmed that the ventilator check for Patient #14 was not being recorded every four hours per policy. She stated the Respiratory Therapist missed the ventilator checks on 2/28/18 at 11:51am and 11:05pm. She explained the ventilator checks were performed every 2 hours for first 48 hours, then every 4 hours and as appropriate.


A review of the facility's cardiopulmonary Policy ID #3551962 entitled, "Mechanical Ventilator" dated last revised 4/2017 documented, " ... "Patients on ventilator support ventilator checks are performed every 2 hours for first 48 hours, then every 4 hours and as appropriate." The policy also listed "Mechanical ventilators will be set up and maintained by a Respiratory Therapist."