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ADVENTHEALTH OCALA 1500 SW 1ST AVE OCALA, FL 34474 Oct. 29, 2014
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview, review of facility Policy and Procedures and record review the facility revealed that nursing supervisor failed for 1 of 10 patients (Patient #1), to ensure nursing supervision to prevent nursing staff from operation of ventilator equipment without proper training and supervision.

Findings:

1.) Medical record review revealed that patient #1 was admitted to this facility on 09/09/2014 for a thoracotomy for a lung mass in his left lung. Postoperatively he developed [DIAGNOSES REDACTED] and required intubation on a " Servo " mechanical ventilator. He failed extubation on two separate occasions. Over a period of 2 weeks patient #1 was unable to be weaned from the ventilator, and required more and more oxygenation to maintain satisfactory oxygen saturations. On 09/23/2014 the physician discussed with patient #1 in detail about current condition and prognosis. On 09/25/2014, prognosis remained poor, and patient #1's wife decided to make him a Do Not Resuscitate (DNR), on a conservative approach, and his physician ordered a consult for Palliative Care. On 09/25/2014 at 2:30 PM patient #1's Palliative Care physician gave a verbal order to Registered Nurse #A (RN) to Extubate-Stop Ventilator-Now.

2.) Interview on 10/29/2014 at 1:20 PM with RN #B revealed that on 09/25/2014, RN #A asked her to assist with patient #1. RN #B stated that RN #A said to her that the physician had ordered her to turn the ventilator off, and that she had called Respiratory Therapy and they are not there yet, and that the physician wanted it done now. RN #B stated that RN #A stated "I need you to turn the ventilator off. " RN #B turned the ventilator off. Then RN #A said " I'm not ready yet " and RN #B turned the ventilator back on and the screen lit up. At that time RN #B 's patient arrived from surgery, and she left patient #1's room.

Further interview with RN #B stated that they should have waited for Respiratory Therapy to arrive to extubate and turn the ventilator off because nursing staff are not trained to extubate and turn off the model Servo or 840 ventilators.

3.) Interview on 10/29/2014 at 1:40 PM of RN #A revealed patient #1's Palliative Care physician told her to medicate patient #1 with Ativan and Morphine for Comfort Measures and then turn off the ventilator. She stated that to turn off the ventilator, means to get Respiratory Therapy to come do it. She paged Respiratory Therapy, went and obtained the medications ordered, and on the way back into patient #1's room she asked RN #B to help her and asked RN #B how and where the button to turn the ventilator off and RN #B said " right here", and she shut the ventilator off. RN #A stated that she said " I'm not ready, " and RN #B left the patient's room. RN #A further stated that the reason I asked RN #B where the button to shut the ventilator off, is because the physician does not deal with ventilators and does not know how to shut them off.

4.) Interview on 1:45 PM of the Respiratory Therapist that had been on duty on 09/25/2014, revealed she responded to the page to patient #1's room, and when she asked RN #A who shut the ventilator off, RN #A stated she didn't know.

5.) Interview on 10/29/2014 at 2:00 PM with the Manager of Cardiopulmonary and Phlebotomy Services revealed that Respiratory Therapy responded on 09/25/2014 at 3:02 PM, always within 15 -20 minutes from the time called, and Registered Nurses (RN's) are not allowed to turn the power off on the Servo mechanical ventilators. They are not proficient in their qualifications and not trained to do so. We put the patients on the 840 and Servo mechanical ventilators and take them off.

6.) Interview on 10/29/2014 at 2:15 PM with the Director of Cardiovascular Intensive Care Unit (CVICU) revealed that adjustments to the Servo ventilator must be done by a Respiratory Therapist (RT).

7.) Review of the facility's Policy and Procedures for Cardiopulmonary Services, titled " End of Life Ventilator Removal Protocol ", last reviewed on 05/29/2013. For patients that have orders to be removed from mechanical ventilation for terminal wean or terminal extubation. Patients that are on minimal support and who are extubated, place on humidified oxygen for comfort measures if ordered by the Physician. If the Respiratory Therapist (RT) is not available within 30 minutes, notify the charge nurse in critical care.

8.) Interview on 10/29/2014 at 3;00 PM with patient #1's Palliative Care physician revealed that when he wrote the order to extubate and stop the ventilator now, he expected that nursing would contact Respiratory Therapy, and that Respiratory would come to the CVICU to discontinue and turn off the ventilator.