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Based on record review and interview, the hospital failed to ensure respiratory services were delivered in accordance with medical staff directives as evidenced by missed doses of Duoneb treatments for 2 (#5, #6) of 2 patients receiving Duoneb treatments on 8/4/15.

Findings:

Review of the hospital policy titled, "Administration of Medications", revealed in part:
Purpose: To establish a system by which medications will be prescribed, dispensed and administered to patients, safely, accurately and efficiently, by qualified personnel.
2. The 5 "R's " of administering medication will be followed with each medication administration: "Right" patient, "Right" medication, "Right" dose, "Right" time and "Right" route.
7. Document the administered dose on the MAR (Medication Administration Record) after given.

Patient #5
Review of the Medication Reconciliation Form for Patient #5 dated 7/20/15 at 4:00 p.m. revealed an order for Albuterol/ Ipratropium (Duoneb) Nebulizer every 6 hours while awake.

Review of the MAR (medication administration record) dated 8/4/15 for Patient #5 revealed Duoneb was scheduled to be given every 6 hours while awake. A dose was given at 5:00 a.m. and another was given at 5:15 p.m. by S7Respiratory (the night respiratory therapist). No doses were documented as having been given during the day shift at 11:00 a.m.

In an interview on 9/10/15 at 8:45 a.m. with S2Quality, she verified there should have been a dose of Duoneb administered at 11:00 a.m. on 8/4/15 for Patient #5 but none was documented.

In an interview on 9/10/15 at 9:24 a.m. with S4RespDir, he said he was not sure why Patient #5 and Patient #6 had missing doses of Duoneb on 8/4/15.

Patient #6
Review of an order for Patient #6 dated 7/2/15 revealed an order for Duoneb 0.5mg (milligrams)/3ml (milliliters) inhalation every 6 hours. Further review revealed an order dated 7/3/15 at 11:50 a.m. to change the Duoneb to every 4 hours.

Review of the MAR for Patient #6 revealed 0.5-2.5 (3) mg/ 3ml was to be given every four hours. Further review revealed it had been documented as having been given at 5:00 a.m., 10:10 a.m. and then not again until 6:00 p.m.

In an interview on 9/10/15 at 8:45 a.m. with S2Quality, she verified there should have been a dose of Duoneb administered to Patient #6 at 2:00 p.m. on 8/4/15 but none was documented.

Based on record review and interview, the hospital failed to ensure respiratory medication orders documented in the patient's medical record were complete as evidenced by failing to ensure the route, indication for administration and frequency was included on all respiratory orders for 4 (#1,#2,#3,#6) of 6 (#1-#6) patients reviewed for respiratory care services.

Findings:

Review of the hospital policy titled, " Physician Respiratory Orders Written and Telephone Guidelines " , Policy#: RT10, Effective date: 7/2013, Review/Revise Date: 9/2014, revealed the following, in part:
Purpose: To clarify and standardize the practice of accepting and writing physician orders in the medical chart.
Policy: It is the policy of the Department of Respiratory Care Services to provide respiratory care as prescribed by physicians.
Procedure: Written orders
4. Orders shall be concise and definite. Medication orders shall include the name of the drug, dosage (metric), route and frequency.

Patient #1
Review of Patient #1 ' s physician orders, dated 8/30/15 at 1:00 p.m., revealed an order for Duoneb q (every) 6 hours and PRN (as needed). Further review revealed no documented evidence of a route of administration for the scheduled/PRN treatments. Additional review revealed no documented evidence of a frequency for the PRN order.

Patient #2
Review of Patient #2 ' s physician routine admission orders, dated 7/21/15 at 5:45 p.m., revealed an order for Duonebs q 6 hours. Further review revealed no documented evidence of a route of administration.

Patient #3
Review of Patient #3 ' s physician orders, dated 9/5/15 at 6:00 a.m., revealed an order for Albuterol 2.5 mg (milligrams)/NS (normal saline) neb (nebulizer) q 4 hours PRN (as needed). Further review revealed no documented evidence of a route of administration or an indication for administration of the PRN dose.

Patient #6
Review of Patient #6 ' s physician orders, dated 7/3/15 at 11:50 a.m., revealed an order to change Duoneb to every 4 hours. Further review revealed no documented evidence of a route of administration.

In an interview on 9/10/15 at 8:59 a.m. with S9Pharmacist (Pharmacy Director), she indicated ordering respiratory treatments PRN without an indication for administration was an incomplete order. She confirmed medication orders lacking a route and a frequency were also incomplete orders that required clarification. S9Pharmacist confirmed the above referenced orders were incomplete orders after reviewing them.

In an interview on 9/10/15 at 9:23 a.m. with S4RespDir (Respiratory Director), he indicated respiratory staff should clarify incomplete respiratory orders. He confirmed orders that lack the route, frequency and indication for administration (PRN orders) were incomplete orders.

In an interview on 9/10/15 at 9:48 a.m. with S8RNManager she indicated nursing staff should have obtained clarification of incomplete medication orders. She agreed the above referenced respiratory orders were incomplete orders that should have been clarified.