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Based upon interview, policy review, and clinical record review, the facility failed to ensure each patient on a ventilator had physician orders for the ventilator ' s settings, and failed to ensure the ventilator weaning protocol was followed as each patient was weaned. This affected four of four sampled patients on a ventilator: Patient #10, #4, #2, and #8. The total sample size was 11 patients, the facility ' s census was 83 patients.

Findings:

See A1160, A1163.

Based on interview and clinical record review, the facility failed to ensure each ventilator patient was weaned according the facility's protocol. This affected one of 11 sampled patients, Patient #10.


Findings:

The clinical record review for the Patient #10 was completed on 03/21/13. The clinical record review revealed the patient was admitted on 02/15/13. The clinical record review revealed a history and physical that stated the 63 year old patient the patient had had an ascending aortic dissection that was surgically repaired. The history and physical stated the patient's hospital course (prior to the transfer to this facility) was complicated by a hemothorax that needed a chest tube, a pseudoaneurysm that needed additional surgical repair, stroke, and respiratory failure that required a tracheostomy and percutaneous endoscopic gastrostomy tube. The history and physical stated the patient is 100 percent on a ventilator.

The clinical record review revealed a physician's progress note dated 02/17/13 that stated he/she was transferred into the facility for weaning off the ventilator and therapies.

The clinical record review revealed a physician's order dated 02/18/13 at 7:00 A.M. that stated " initiate vent wean protocol " .

Review of the facility's undated ventilator weaning protocol was completed on 03/21/13. The review revealed criteria that needed to be met before the patient could be weaned. These included a systolic blood pressure of less than or equal to 140 millimeters mercury, and spontaneous tidal volume of 3-5 milliliters/kilogram ideal body weight.

The clinical record review did not reveal what the patient's ideal body weight was.

The clinical record review revealed on 02/18/13 at 3:45 A.M. the patient's systolic blood pressure was 148 millimeters mercury. The clinical record review revealed the patient's weaning began at 7:15 A.M. and at 7:50 A.M. the patient's systolic blood pressure was 171 millimeters mercury. The weaning did not stop until 10:08 A.M.

Review of the facility's undated ventilator weaning protocol completed on 03/21/13 revealed the patient is to be weaned in stages, with stage one being between 5 and 120 minutes, stage 2 between 2 and 4 hours, stage 3 between 4 and 8 hours, stage 4 between 8 and 12 hours, and stage 5 between 12 and 16 hours.

Again, the clinical record review revealed on 02/18/13 the patient was weaned from 7:15 A.M. to 10:08 A.M., a little less than 3 hours (and more than the 2 hours required at stage 1 in the protocol).

The clinical record review revealed on 02/19/13 the patient was weaned from 7:15 A.M. to 1:20 P.M., a little more than six hours (and more than the 4 hours required at stage 2 in the protocol).

On 02/20/13 at 2:15 P.M. in an interview, Staff D stated he/she could not find the patient's ideal body weight in the chart. He/she confirmed on 02/18/13 and on 02/19/13 the patient was weaned longer than stages called for in the protocol.

Findings include:

The clinical record review for Patient # 4 was completed on 03/21/13. The patient was admitted to the hospital on 03/01/13 with a diagnosis of acute respiratory failure. The patient was admitted from a nearby acute care hospital already ventilated. The pre-printed physician orders for the admitting hospital included that of "continue current ventilator settings". This order however, was not "checkmarked" as having been addressed. Staff C, who was with the surveyor during record review on 03/20/13 at 2:20 PM, confirmed the ventilator settings were programmed without a physician order.



21521

Based on interview, clinical record review, and policy review, the facility failed to ensure each patient on a ventilator had physician orders for its settings. This affected Patient #10, #2, #4, and #8. The sample size was 11 patients, and the census was 83 patients.

Findings:

The clinical record review for the Patient #10 was completed on 03/21/13. The clinical record review revealed the patient was admitted on 02/15/13 at 3:21 P.M. The clinical record review revealed a history and physical that stated the 63 year old patient the patient had had an ascending aortic dissection that was surgically repaired. The history and physical stated the patient's hospital course (prior to the transfer to this facility) was complicated by a hemothorax that needed a chest tube, a pseudoaneurysm that needed additional surgical repair, stroke, and respiratory failure that required a tracheostomy and percutaneous endoscopic gastrostomy tube. The history and physical stated the patient is 100 percent on a ventilator.

The clinical record review revealed a physician's progress note dated 02/17/13 that stated he/she was transferred into the facility for weaning off the ventilator and therapies.

The clinical record review revealed a respiratory therapist note dated 02/15/13 at 3:25 P.M. that stated the patient was on 40 percent oxygen, 12 assist control, and tidal volume 600 milliters, along with apnea parameters set at an interval of 20 seconds.

The clinical record review revealed these settings were maintained until 02/17/13.

The clinical record review revealed the first physician's ventilator order was dated two days after admission, on 02/17/13 at 12:23 P.M., for the following ventilator settings: assist control 12 breaths, tidal volume of 600 milliliters, positive end expiratory pressure of 5 millimeters mercury, and 40 percent oxygen.

On 03/20/13 at 2:15 P.M. in an interview Staff D confirmed the order was written two days after admission. He/she also stated the patient's apnea monitors are selected based upon the respiratory therapist's discretion.

Review of the respiratory therapist job description was completed on 03/21/13. The review revealed the respiratory therapist's scope of practice was under physician prescription or medical direction.

Review of the facility's plan for the provision of patient care was completed on 03/21/13. The review revealed respiratory therapists are to operate within the scope of their practice and are responsible for implementing physician respiratory therapy orders.




31007

Review of clinical record for Pt. #8 completed on 03/20/13 revealed a diagnosis of Respiratory Failure and an admit date of 03/11/13. The patient was admitted from another hospital already on the ventilator. Further review revealed lack of documentation for ventilator orders upon admission. The first order for settings of the ventilator was noted to have been written on 03/12/13, the order stated to increase the VT to 500 ml and decrease the PEEP to 5. This was verified by Staff A on 03/20/13 at 3:45 PM.








31159


Review of the clinical record for Patient #2 was completed on 03/20/13 at 3:30 PM. The 35-year old patient was admitted to the long term acute care hospital (LTAC) 03/12/13 with diagnoses including chronic respiratory failure, apnea (suspension of normal breathing), and obesity. Review of the clinical record revealed Patient #2 was a transfer patient who came from a nearby hospital and had a tracheostomy (surgical opening through the neck in to the windpipe) with a tracheostomy tube and was on a mechanical ventilator at the time of admission to the LTAC. The clinical record revealed a respiratory care mechanical ventilator flow sheet dated 03/12/13 documenting the ventilator settings respiratory care applied to Patient #2. The clinical record lacked documentation of a physician's order for the specific ventilator settings.
In an interview with Staff B on 03/20/13 at 3:40 PM, Staff B stated that when a patient comes from another hospital and they are already ventilated, the respiratory staff follows the ventilator settings the patient was on previously.