HospitalInspections.org

Based on medical record review, document review and staff interview, the facility failed to provide respiratory treatments within 60 minutes of scheduled time in accordance with the facility policy and procedure. This finding is evident in 5 of 14 medical records reviewed (Patient #s 1, 3, 4, 5, and 6).

Findings include:

The review of facility policy titled: "Medication Administration and Documentation Policy #MM 06.01.01" last revised 9/17 revealed that medications are to be given and documented within 60 minutes of scheduled time.

Review of medical record for Patient #1 identified a physician order for Albuterol 0.042%, 1.25 milligram (mg)/3milliter (ml), every six hours, to be given at 8:30AM, 2:30PM, 8:30PM and 02:30AM.
Medication Administration Record revealed that on 11/10/18, the 8:30 AM dose was given at 9:42AM, 42 minutes late.
On 11/12/18, the 8:30 PM dose was given 44 minutes late at 10:44PM.

The same patient was late in receiving Flovent 110 microgram (mcg) inhaler that was ordered to be given twice daily at 8:30AM and 8:30PM.
On 11/6/18, the 8:30AM dose was given at 9:56AM, 56 minutes late, and the 8:30PM dose was given at 9:43PM, 43 minutes late.
On 11/10/18, the 8:30AM dose of Flovent was given at 9:43AM, 43 minutes late.


Review of medical record for Patient #3 revealed a total of 13 medication doses were given late within a seven-day period.

Albuterol Sulfate 0.5% 2.5 mg inhaler was ordered to be given at 1:30AM, 7:30AM, 1:00PM and 7:30PM.
On 11/06/18, the 7:30 AM dose was given 40 minutes late at 8:40 AM.
On 11/11/18, the 7:30 AM dose was given 41 minutes late at 8:41AM.
On 11/12/18, the 7:30 AM dose was given 60 minutes late at 9:00AM and on 11/12/18, the 7:30 AM dose was 68 minutes late.

The same patient was on Flovent 110 mcg inhaler twice daily (BID). The medication was given 41 minutes late on 11/11/18 at 8:41AM and 69 minutes late on 11/12/18 at 9:09AM.

Tobramycin Sulfate 80 mg BID was ordered to be given at 7:30AM and 7:30PM. The medication was given late 5 times within a week.
On 11/7/18 at 8:54PM, after 54 minutes of the due period;
On 11/10/18 at 8:34AM, after 34 minutes of the due period;
On 11/11/18 at 8:41AM, after 41 minutes of the due period;
On 11/12 /18 at 9:09AM, after 69 minutes of the due period;
On 11/12/18 at 9:08PM, after 68 minutes of the due period.

Similar findings regarding late administration of medications were noted for Patient #s 4, 5 and 6, whose medications were not administered within 60 minutes of the scheduled time.

During interview on 11/13/18 at 2:05PM, Staff A, Director of Respiratory Services and Staff B, Director of Nursing acknowledged findings.