HospitalInspections.org

Based on record review, policy and procedure review, and interviews, the Hospital failed to ensure that for one patient, (Patient #1), out of a total sample of 10 patients, the Plan of Care with regard to the administration of oxygen was followed according to Practitioner's orders. Findings include:

A review of Pt. #1's Medical Record indicated Patient (Pt.) #1 was admitted to the Hospital on 4/25/14. Pt. #1 had an extensive medical history which included heart disease, high blood pressure, hyperlipidemia (high cholesterol), and end-stage chronic obstructive lung disease (COPD- a progressive lung disease). The Record indicated that Pt. #1 was oxygen dependent and used a nasal cannula (delivery of oxygen via a tube which on one end splits into two prongs that are placed in the nostrils) during the day and BiPAP (bi-level positive airway pressure-a machine with an oxygen mask that helps keep the upper airways of the lungs open) with entrained (supplemental oxygen fed into tubing) oxygen at night. The Record indicated that Pt. #1 rapidly desaturated (a condition in which the level of oxygen dissolved in the blood is decreased) if left off oxygen for any length of time.
Review of Physician Orders, timed and dated 7:10 P.M., on 4/25/14 indicated that Pt.#1 was to be on 4 liters (amount of oxygen) of oxygen by nasal cannula.
The Surveyor interviewed Nurse #1 at 11:45 A.M. on 8/12/14. Nurse #1 said that she was Patient #1's caregiver on the 3:00 P.M. to 11:00 P.M. shift on 4/25/14. Nurse #1 said that at approximately 9:50 P.M on 4/24/14, she had gone into Pt. #1's room to administer Pt. #1's evening medications as well as a nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) treatment. Nurse #1 said that Pt. #1 was on his/her BiPAP machine when she entered the room. Nurse #1 said that Pt. #1 pulled his/her BiPAP mask off in order to take his/her medications. Nurse #2 said that she did not bring the nebulizer set-up with her and had to leave the room for 2-3 minutes to get the needed supplies and did not put Pt. #1's nasal oxygen when she left. Nurse #1 said that she returned to Pt. #1's room and Pt. #1 was upset and had desaturated to 76% (normal saturation 95-100 percent with COPD patients often aim for saturation of 88-92%).
Nurse #1 said that she replaced the nasal oxygen and PT #1's saturation improved to approximately 94% in a few minutes.