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Based on observation and interview the facility failed to provide a written policy regarding the procedure for ensuring patient's need and request for respiratory treatments is addressed timely and failed to ensure respiratory equipment is dated when changed (A-1160) and failed to ensure the patient's medical record documented who provided the respiratory care service including extubation of the patient (A1164).
The cumulative affect of this systemic process resulted in the inability of the facility to provide respiratory treatments as ordered at the time a patient is experiencing shortness of breath.

Based on medical record reviews and staff interviews, the facility failed to ensure nursing developed a care plan for four of ten patients reviewed. This affected Patients #1, #5, #7 and #8. The facility had a current census of 34 patients at the time of the survey.

Findings include:

1. On 06/27/17 a medical record review was completed for Patient #1. This patient was admitted on 06/15/17 with diagnoses of Aspiration pneumonia, Chronic atrial fibrillation, Parkinson's, Hemiparesis (paralysis) right side post stroke. The patient had bilateral wrist restraints for pulling of tubes and used oxygen per nasal cannula. There was no evidence of a nursing care plan for the restraints, behavior and oxygen use.

2. On 06/27/17 a medical record review was completed for Patient #5. The patient was admitted on 06/13/17 and expired on 06/18/17. The patient was admitted from an acute care hospital with diagnoses of Respiratory failure, pneumonia with Pseudomonas and MRSA, Pseudomonas bacteremia, sepsis, a long history of COPD, Diabetes Mellitus, and Chronic kidney disease. The patient had acute decompensated congestive heart failure along with acute chronic respiratory failure with both hypoxia and hypercapnia and was chronically anemic. The patient had a ventilator in place and wrist restraints. There was no evidence of a care plan for these care needs.

This was confirmed by Staff E and Staff L on 06/27/17.

3. Patient #7 was admitted on 06/21/17 with diagnosis of acute respiratory failure. The patient had a catheter for hemodialysis and was receiving respiratory care due to being on a ventilator and having a tracheostomy. A medical record review revealed there was no nursing care plan to address the respiratory and dialysis needs of this patient.

4. A record review was completed on 06/27/17 for Patient #8. The patient had an admission date of 06/14/17 and diagnosis of Respiratory Failure. The patient was admitted on a ventilator. The MAR review revealed a physician ordered respiratory medication was not given on 06/17/17 at 8:00 AM. The nursing care plan lacked evidence of respiratory interventions.

This was confirmed with Staff L and Staff G on 06/27/17 at 9:36 AM.

These aforementioned patients' care plans were confirmed with Staff G on 06/27/17. Staff B and Staff C were made aware of the lack of care plans on the same date.

Based on medical record reviews, review of medication administration policies and staff interviews, the facility failed to ensure medications were administered in accordance with physicians' orders. This affected 6 of ten patients reviewed. (Patients #1, #2, #5, #6, #7, and #8) The current census was 34 patients at this location at the time of the survey.

Findings include:

1. On 06/27/17 a record review was completed for Patient #1. This patient was admitted on 06/15/17 with diagnoses of Aspiration pneumonia, Chronic atrial fibrillation, Parkinson's, Hemiparesis (paralysis) right side post stroke.

The medical record contained the following documentation in regard to physician ordered medications which were not given by staff:

a. Missed medication Significant Event authored by a physician for all doses of medications ( a total of five medications) due between the time of admission and 7:00 AM the next morning have not been given due to the physician's orders had not been released from the prior facility.

b. Staff G confirmed on 06/27/17 at 12:45 PM an intravenous (IV) medication (Zosyn) had not been given on 06/20/17 at 6:00 PM. This was documented in a pharmacy note by the pharmacist. According to Staff G, the 6:00 PM dose of Zosyn was returned to the pharmacy at 6:00 AM the next morning.

c. Sinemet (Parkinson's medication) was not given at 06/16/17 at 3:42 AM "due to nursing work flow too close to another dose" as documented in the medical record.

d. A dry mouth solution was ordered by the physician, two sprays, three times a day. The medication administration record review revealed this spray was not given on 06/21/17 at 8:45 AM due to not being available.


2. Review of the medical record for Patient #2 revealed Patient #2 was admitted on 06/15/17 with respiratory failure with hypoxia. Review of the physician orders revealed orders for Pulmicort (steroid medication) 0.5 milligrams, two times daily by nebulization (inhalation treatment); albuterol (bronchodilator) 2.5 milligrams, every four hours by respiratory treatment and Lopressor (medication for high blood pressure) 25 mg, two times daily, by mouth.

Review of the Medication Administration Record (MAR) for Patient #2 revealed Pulmicort was not given on 06/16/17 at 11:30 AM. The reason documented was "parameters not met". Review of the physician's orders revealed no parameters were specified in the orders for the Pulmicort medication orders. Review of the MAR revealed albuterol was not given on 06/21/17 at 5:00 PM. No reason was given as to why the medication was not administered as ordered. Further review of the MAR revealed Lopressor was not given on 06/16/17 at 11:47 PM, 06/19/17 at 10:14 AM and 06/21/17 at 9:38 AM. The reason documented was pulse was 55 beats per minute on 06/16/17 at 11:47 PM, pulse was 64 per minute on 06/19/17 at 10:14 AM and pulse was 58 per minute on 06/21/17 at 9:38 AM.

On 06/23/17 at 3:30 PM, Staff D confirmed there was no ordered parameters for these medications and the physician was not notified for orders to hold these medications.

3. On 06/27/17 a medical record review was completed for Patient #5. The patient was admitted on 06/13/17 and expired on 06/18/17. The patient was admitted from an acute care hospital with diagnoses of Respiratory failure, pneumonia with Pseudomonas and MRSA, Pseudomonas bacteremia, sepsis, a long history of COPD, Diabetes Mellitus, and Chronic kidney disease. The patient had acute decompensated congestive heart failure along with acute chronic respiratory failure with both hypoxia and hypercapnia and was chronically anemic.

The medical record review revealed an inhalant respiratory medication (Atrovent 0.02%) ordered by the physician for two times a day was not administered on 06/17/17 at 8:00 AM listing the reason as "Other." A heart medication (Cardizem 60 mg was not given on 06/15/17 at 1:27 PM due to "order parameters not met". The medical record was silent to parameters for this medication.

4. The medical record review on 06/27/17 for Patient #6 revealed an admission date of 06/10/17 and diagnoses of acute and chronic respiratory failure with hypoxia, squamous cell carcinoma of larynx, Atrial Fibrillation, essential hypertension and seizure. 06/24/17 at 1642 Not given: Artificial tears 1.4% ophthalmic solution 3 times a day ordered 06/10/17. Medication NOT available. The medication administration record (MAR) revealed that an antibiotic ophthalmic solution of Ciprofloxacin 0.3% was ordered to be given two drops two times a day starting on 06/10/17. This medication was not given at 10:00 AM on 06/14/17 for the reason of "Other". Decadron 0.1% solution ordered for each ear two times a day was not given at 10:00 AM on 06/14/17 for the reason of "Other".

Further record review with Staff G on 06/27/17 at 12:08 PM confirmed these medications were ordered at 10:00 AM and were not given until 11:38 AM on that date. Staff G confirmed the MAR contained directions to give the medications within 60 minutes of the ordered time. According to Staff G, the medications should have been administered 60 minutes from due time on MAR. Staff G stated the late medication administration should have been reported to the physician.

5. The medical record review was completed on 06/27/17 for Patient #7. The patient's admission date was 06/21/17 post lung transplant and diagnosis of acute respiratory failure. The patient had a tunneled catheter for hemodialysis treatments three times a week. The patient was on a ventilator. A review of the MAR revealed a Lidocaine 5% patch not placed on the patient on 06/24/17 at 10:11 PM due to not being available. Lopressor medication was not given on 06/24/17 at 6:09 AM due to reason of "contraindicated". This medication was not given on 06/26/17 at 6:14 AM for reason of "Other".

Staff E confirmed the aforementioned documentation on 06/27/17 at 12:45 PM.

6. A medical record review was completed on 06/27/17 for Patient #8. The patient had an admission date of 06/14/17 and diagnosis of Respiratory Failure. The patient was admitted on a ventilator. The MAR review revealed a physician ordered respiratory medication was not given on 06/17/17 at 8:00 AM.

Interviews were conducted with Staff C, Staff E, Staff G, and Staff M on 06/27/17. There was no additional information provided in regard to the aforementioned medications not being given as ordered, nor was clarification and documentation provided for the reason of "other" and "parameters not met".

Based on observation and interview the facility failed to ensure the patient's needs and request for respiratory treatments was addressed timely and failed to ensure the suction tubing was dated when changed. This affected one (Patient #10) patient of 18 current (artificial) airway patients. Ten medical records were reviewed with a current census of 34 at the time of the survey.

Findings include:

Performance of a respiratory treatment was observed on 6/26/17 at 12:02 PM. Staff L entered the room (220) of Patient #9 at 12:00 PM with gown and gloves donned as the patient was in contact isolation. At 12:01 PM Staff L received a call on his/her radio communication device stating respiratory therapy was needed in room 230. Staff L responded back relaying his/her inability to check the patient in room 230 and asked that one of the other two respiratory therapists on the unit check the patient. Staff L continued to Patient #9's bedside and administered the ordered respiratory treatment and performed tracheostomy care. At 12:12 PM when Staff L completed his/her duties in Patient #9's room, he/she reported that he/she did not hear a response from the other two respiratory therapists regarding the call from room 230. Staff F, the Respiratory Therapy Manager, who was also observing Staff L, reported he too, had not heard a response from either of the two therapists.

At 12:15 PM Staff L entered room 230, bed #1 and asked the patient (Patient #10) if he had requested respiratory therapy. "Yeah, I need a breathing treatment", Patient #10 responded. Staff L verified the physician order for the respiratory treatment, assessed the patient and proceeded with the process of administration of DuoNeb as ordered at 12:21 PM.

Staff F was interviewed at 12:17 PM as to the appropriateness of the lack of response from the other two respiratory therapists. Staff F reported, "they both should have responded, my guess is they were in a patient's room and couldn't get to their radios."

Staff F was again interviewed at 2:05 PM and reported that both respiratory therapists were counseled to turn up the volume on their radio.

An interview with Staff C, Chief Nursing officer, was completed on 6/26/17 at 4:45 PM. Staff C reported he/she had spoken to each of the two respiratory therapists him/herself and both denied having been counseled by Staff F to turn the volume up on their radios.

An interview with Staff B, CEO, was completed on 6/26/17 at 4:46 PM. Staff B reported the hospital has no policy that directs respiratory therapy staff to respond to patient requests for PRN (as needed) respiratory treatments. Staff B explained it is a "core value" that all staff members know "patients come first". "We expect no more than a three minute response time to a call from a patient, not the 10-12 minutes (Patient #10) waited." Staff B confirmed during the interview, " the expectation would have been for Staff F to respond knowing Staff L was already providing care to a patient and the other two respiratory therapists didn't respond."

A tour of the facility on 06/23/17 and observations on 06/26/17 of patients in room 228-2, 241 and 250 revealed the closed suction tubing connected to the patients' tracheostomy had no evidence of a date when the tubing was last changed.

Review of policy titled: S05-G Guidelines and protocols revealed the closed suction system should be changed weekly and as needed.

According to interview with Respiratory Therapist Staff P and R, staff were supposed to date the closed suction tubing when it was changed.

Based on observation and interview the facility failed to document extubation (removal of an airway device) of a patient on a ventilator. This affected one (Patient #8) of ten patient medical records reviewed. The current census was 34 patients.

Findings include:

On 06/27/17 a review was completed of Patient #8's medical record. The patient was admitted on 06/14/17 with a diagnosis of Respiratory Failure and was on a ventilator. The patient remained on the ventilator until 06/19/17 according to a nursing progress note dated 06/19/17 at 11:54 AM. The progress note contained documentation the patient was successfully extubated but failed to address the respiratory therapist who extubated the patient.

On 06/27/17 at 12:30 PM interview was conducted with Staff E and Staff M regarding documenation of who extubated the patient. Both staff were unable to provide this documentation.