HospitalInspections.org

Based on document review and interview, the hospital failed to ensure that nursing care assignments were in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available for 1 of 1 patients (P4) with a respiratory incident related to nursing.

Findings include:

1. Review of the policy titled "Ventilation, Non-invasive (CPAP/BIPAP), continuous positive airway pressure/bilevel positive airway pressure, Revised Date: 04/01/19, indicated the following:
Scope: Respiratory Therapists
Note: For Inpatient Rehabilitation facilities in which 24 hour respiratory care is not provided, procedure may be performed by nursing personnel which have demonstrated competency...

2. The MR of patient P4 indicated the following: Physician Progress Notes dated 5/30/19, time not noted, indicated: "Rapid response" this am (morning), was off "Bipap & vapotherm not on - Placed back on Bipap".

3. Review of facility incident reports indicated that on 5/30/19 an incident related to patient P4 was documented with the following information: "Nurse removed BIPAP mask to give patient oral meds. Did not put patient on any oxygen sourse (sic). Patient desated to 50% nurse left room to get another nurse for help. "Neither" nurse knew how to operated (sic) vapotherm for patient. Nurse said patient turned gray. Rapid response was called." Hand written information on the front of the report indicated the following: RT Manager and Nurse Manager spoke with RN. "Re-educated" regarding increased FiO2 (Fraction of Inspired Oxygen) and bipap removal should be with RT.

4. On 6/27/19, between approximately 1:30 p.m. and 3:30 p.m., staff A2, Director of Quality Management indicated that registered nurse (RN) S1 and RN S2 were the nurses involved in the above incident.

5. Personnel file review indicated the following:
Employee S1, RN was a contracted agency nurse. The file lacked documentation of orientation to his/her job and lacked documentation of competencies; including, but not limited to respiratory care and treatment of patients.
Employee S2, RN was a direct employee of the facility. The file lacked documentation of competency evaluations since 2007.

Based on document review and interview, the medical records (MR) for 2 of 10 patients (P1 and P4) lacked information describing patient's response(s) to respiratory care and changes in progress/condition and lacked rapid response documentation in accordance with facility policy for patient P4 in 2 of 3 instances.

Findings include:

1. Policy and Procedure review:
A. Review of the policy titled "Oxygen Administration", Origination Date: 01/01/19, indicated the following: All changes and reasons for such changes should be noted in the medical record, and the physician should be notified if patient requires a significant increase in FIO2 (Fraction of Inspired Oxygen).

B. Review of the policy titled "Change in Patient Condition", Revised Dated 10/01/18, indicated the following:
Documentation: The complete assessment should appear on the nursing flow sheet/EMR (Electronic Medical Record). The change in condition and physician communication should be documented in the clinical notes or EMR.
When a Rapid Response Team (RRT) is initiated, utilize the RRT Response Record/EMR to document assessment data, interventions and physician communication. For paper RRT Response Records, the white copy is placed in the progress notes...

2. Review of MRs indicated the following:
A. The MR of patient P1 indicated that on 5/27/19 at 1009 hours, an "RRT" (Rapid Response Team) was called to the patient. The "RRT Response Record" indicated the following: Reason Called: "desats to 50%, brady to 40's" (oxygen saturation dropped to 50% and the heart rate to the 40s). The MR lacked information describing the change in condition precursors related to the drop in the patient's oxygen and/or heart rate levels. From MR documentation, it could not be determined what the patient and/or staff was doing at the time of the sudden change in condition.

B. The MR of patient P4 indicated the following:
i. A rapid response was called on "5/27/18" (sic) at 1847 hours as follows: Reason Called: "Desats to 50%, Pt (patient) had coughing spell".
ii. The MR indicated a rapid response was called on "5/29/18" (sic) as follows: Reason Called: "Decreased O2 sats". The "RRT Response Record" lacked documentation of "Physician Notification" and signature of RRT RN (Registered Nurse). The MR lacked description of the change in condition precursors related to the drop in the patient's oxygen and/or heart rate levels.
iii. Physician Progress Notes dated 5/30/19, time not noted, indicated the following: "Rapid response" this am (morning), was off "Bipap & vapotherm not on - Placed back on Bipap". Nursing and RT notes, lacked documentation of reasons for the change in condition or the reason the patient was off bipap and off vapotherm. The MR lacked documentation of a "RRT Response Record".

3. Review of facility incident reports indicated that on 5/30/19 an incident related to patient P4 was documented with the following information: "Nurse removed BIPAP mask to give patient oral meds. Did not put patient on any oxygen sourse (sic). Patient desated to 50% nurse left room to get another nurse for help. "Neither" nurse knew how to operated (sic) vapotherm for patient. Nurse said patient turned gray. Rapid response was called."

4. On 6/27/19, between approximately 1:30 p.m. and 3:30 p.m., A2, Director of Quality Manager, and A3, Nurse Manager, verified lack of MR documentation describing patient's responses and changes in progress causing significant drops in oxygen saturation for patient P1 and for 2 of 3 rapid responses for patient P4. They also verified that the MR for patient P4 lacked a "RRT Response Record" and by physician note and incident report, the patient not only had a rapid response on 5/27/19 and 5/29/19; he/she also had a rapid response on 5/30/19. A2 verified that the RRT Response Record for patient P4 dated 5/29/19 lacked documentation of Physician Notification and the signature of the RRT RN.

Based on document review and interview, the hospital failed to ensure respiratory services delivered care in accordance with medical staff directives for 2 of 10 patients (P2 and P3).

Findings include:

1. Review of the policy titled Protocols, Physician Orders, Origination Date 01/01/19, indicated the following: Documentation by the therapist should provide sufficient information to validate criteria for inclusion, exclusion, continuation, or discontinuation of the protocol.

2. Review of medical records indicated the following:
A. The MR of patient P2 indicated the patient was admitted 5/23/19 and discharged 6/6/19. Located in the RT section of the MR was a physician's order which indicated that on 5/24/19 at 11:00 a.m., the physician ordered "RT Bronchodilator Administration Protocol". The "Aerosol Assessment Protocol Assessment Sheet" was blank and the MR lacked documentation of RT having completed an assessment as per the protocol orders.

B. The MR of patient P3 indicated the patient was admitted 6/6/19 and expired on 6/9/19. Physician admission orders, dated 6/6/19, indicated the following: Ancillary Consults: "Respiratory to eval & treat" (respiratory therapy to evaluate and treat). The MR lacked documentation of a respiratory evaluation for treatment.