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Based upon observation, interview, and record review the facility failed to ensure that respiratory staff was appropriately qualified to perform specific procedures and provide care for 1 of 10 sampled patients (Patient #1).

The facility failed to ensure:

1. Accurate pre-admission (transfer) assessment information was obtained and communicated to direct care staff.

2. Respiratory Staff ID # 6 was adequately trained to operate certain patient care equipment and to adhere to facility policy regarding contacting supervisor and clarification of physician orders.

These deficient practices affect all inpatients and could cause an inappropriate or delay in patient treatment, as well as increased stress/ anxiety for the patient and/ or family. members.

Findings include:

TX # 00174988

Record review on 04-03-13 of intake TX 00174988 revealed allegation that Patient # 1 had not been provided the proper " Vapotherm " oxygen equipment upon transfer from an acute hospital on 02-18-13. In addition, complainant alleged the next day; the Vapotherm equipment was provided but malfunctioned shortly after being installed. A part was replaced; the following morning the machine clogged. The facility had no back up Vapotherm machine. Complainant alleged Patient # 1 ' s " equipment needs were not fully understood prior to being accepted ... "

Record review on 04-04-13 of Patient # 1 ' s clinical record revealed she was 84 years old and admitted to the facility on 02-18-13 at 9:40 p.m. via an ambulance from an acute care hospital. Patent # 1 ' s history included Acute Hypoxic Respiratory failure, Pneumonia, Pulmonary Fibrosis, Hypertension, and Coronary Artery Disease. Review of the Expiration Summary revealed Patient # 1 had been changed from a full code status to a Do Not Resuscitate (DNR) status. Her conditioned worsened and she experienced " pulseless electrical activity and became unresponsive. " Patient # 1 expired on 02-23-13.

1.

Interview via telephone on 04-04-13 at 11:15 a.m. with Clinical Liaison Staff ID # 7 she stated her responsibility was to assess patients prior to transfer/admission. This process included medical record review and visual observation of the patient, as well as speaking with staff caring for the patient. Staff ID # 7 acknowledged she was the person who completed the pre-transfer assessment on Patient # 1. Staff ID # was unable to recall if the patient had a Vapotherm oxygen delivery system or some other type of machine in the room. She said that whatever was documented on the " ePace ' (pre-admission evaluation) Form was what she saw or read in the medical record regarding Patient # 1.

Review of facility policy titled " Patient Referrals 1.0, " undated, read: " ...All referred patients are screened prior to admission using the PACE forms ...Hospital Administration shall review all applicable clinical and financial information to determine if patient meets criteria .....Upon approval ...the Admission ' s office shall arrange transfer with the referring facility and ensure appropriate bed assignment is made and communicated to appropriate business office and clinical personnel.. " The policy did not address the process for identifying appropriate equipment based on patient ' s assessed needs.

Review of Pre-Admission Clinical Evaluation ( " ePACE " ) for Patient # 1, dated 02-15-13, read " ...Oxygen at 4 liters per minute per nasal cannula ...on PEEP (positive expiratory end pressure) nasal cannula ... " There was no documentation the patient was on a Vapotherm machine.

Interview on 04-04-13 at10:45 a.m. with the Director of Respiratory Department ID # 4, he stated he was familiar with Patient # 1 and recalled her situation well. Staff ID # 4 said the information provided the respiratory department prior to Patient # 1 arriving was that she was on oxygen 4 liters per minute per nasal cannula. His department had not been informed Patient # 1 was in need of a Vapotherm.

Director of Respiratory Staff Id # 4 reviewed the pre-admission evaluation (ePACE) form for Patient # 1 and stated that a patient could not be on " oxygen at 4 liters per minute " and on " PEEP nasal cannula, " as was documented. He stated that PEEP oxygen was delivered at eight (8) liters per minute or higher.

2.

Continued interview with Director of Respiratory Therapy Staff ID # 4 he acknowledged the Vapotherm machine was ordered by the physician on admission for Patient # 1. (Vapotherm is an oxygen delivery system that delivers a high concentration of humidified oxygen via nasal cannula). He went on to say when night shift Respiratory Therapist (RT) #6 was unable to locate the special oxygen cannula that fit the Vapotherm machine; he placed Patient # 1 on a non-rebreather oxygen mask. The Director of RT (ID # 4) stated that RT # 6 should have telephoned him (as his supervisor) or clarified with the physician that it was acceptable to use the non-rebreather oxygen mask instead of the Vapotherm as ordered.

Director of RT (ID # 4) continued and said when he arrived the next morning (2-19-13), he and RT # 6 worked together to set up the Vapotherm machine for Patient # 1. Later that morning Patient #1 ' s daughter reported something was wrong with the Vapotherm machine. The Director of RT (ID #4) said he investigated and found that RT # 6 had incorrectly placed a bag of normal saline fluid instead of sterile water to humidify the air in the Vapotherm machine. The saline had clogged the filter and had pressurized the bag. The Director said he exchanged the humidifying fluid to sterile water and explained to the family members in the room what had happened.

Director of RT ID # 4 reported the next day (2-20-13), the machine filter was again clogged, thought to be a result of some saline left in the tubing. He reported they had no " back-up " Vapotherm machine. It was decided at this time by the physician to place Patient # 1 on a non-rebreather mask. The RT Director (ID # 4) said Patient # 1 ' s daughter was very upset about the Vapotherm " malfunction; " and he apologized and explained what happened.

Continued interview with Director of RT ID # 4 , he said he in-serviced RT #6 on proper set-up of the Vapotherm ( where supplies kept and use of sterile water and not normal saline); he did not document this in-service. RT Director said he did not in-service all of the RT staff concerning the Vapotherm. He reported he obtained an additional back-up Vapotherm and the " step by step " instructions were printed on the inside of each machine.

Observation on 04-04-13 at 10:50 a.m. in the Respiratory Therapy supply room revealed two (2) plastic covered Vapotherm oxygen delivery machines. Neither machine had step-by-step instructions printed on the inside or attached to the machine itself. The Director of RT (ID #4) later produced a copy of the instructions for surveyor review. He stated these were normally displayed in the supply room on the bulletin board, but had been moved when the room was reorganized.