HospitalInspections.org

Based on interview and record review, the facility failed to provide a written policy regarding labeling a nebulizer (a device used to administer medication in the form of a mist inhaled into the lungs) equipment and checking the label before administering treatments to patients, which resulted in one patient (Patient B) being given a nebulizer treatment with soiled equipment.
Findings:

The facility reported that on 11/5/11 at 6:15 PM, a Respiratory Therapist (RT) gave Patient B a nebulizer treatment with equipment that did not belong to the patient.
During an interview with the Director of Patient Care Services (DPCS) on 12/30/11 at 2 PM, she stated that after the incident, a consultant came in and found that some nebulizers had names of patients on them and some did not.. The DPCS also stated Patient B was immunocompromised (having an immune system that has been impaired). The DPCS indicated the patient who the equipment belonged to (Patient D) had not had her sputum cultured, but had been on two different antibiotics.
During an interview with the Quality Improvement Supervisor (QIS) on 12/30/11 at 2:40 PM, she stated Patient D's name was on the equipment used for Patient B. Patient D had been in the same room as Patient C, who subsequently was moved into Patient B's room.
During an interview with the Manager of Respiratory Therapy (MRT) on 12/30/11 at 2:45 PM, he stated Patient D was discharged from the hospital on 10/26/11. The MRT added that RT 1 should have looked at the label before giving the treatment.
The clinical record for Patient B indicated the nebulizer treatment began on 11/4/11 at 12:55 PM and was given every four hours until 11/5/11 at 6:15 PM, when the contaminated equipment was discovered.
During an interview with RT 4 on 1/30/12 at 1:07 PM, he indicated he worked night shift on 11/4/11 and gave Patient B his nebulizer treatments. RT 4 stated "I don't recall if the set-up was labeled. That day I took it for granted."
During an interview with RT 1 on 1/30/12 at 1:21 PM, he stated he went in to give Patient B his treatment, and grabbed the nebulizer. "At some point [Family Member (FM) 1] said a family member observed that the bag had someone else's name on it...I looked at the bag, and scribbled on it, was a name lightly and poorly written. At that point, I stopped the treatment. It had been going about 2-3 minutes...I just had assumed the bag wasn't labeled." RT 1 added that he had not looked at the name on the bag when he first entered the room.
During an interview with FM 1 on 1/31/12 at 1:36 PM, she stated she was with Patient B almost 24 hours a day while he was in the hospital. FM 1 indicated, "The very first and all subsequent treatments were given with the wrong nebulizer until it was discovered." FM 1 added her son saw the name on the bag at least a day and a half after the treatments began. When asked if the lettering on the bag was faint, FM 1 replied "No, not true. I have the bag." FM 1 went on to say the bag had Patient D's name on it and was dated 10/23/11.
During an interview with the MRT on 2/1/12 at 3:03 PM, he stated the instructions to the RT's to label the nebulizer equipment was given by word of mouth. The MRT did not submit a policy that directed staff to label nebulizer equipment with patients' names or to look at the labels before administering treatments. "It was a known expectation...Unfortunately, I was brand new when this happened."