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INTENSIVE SPECIALTY HOSPITAL
RESPIRATORY CARE SERVICES POLICIES
Tag No.: A1160
Based on record reviews and interview, the hospital failed to ensure respiratory services were administered in accordance with hospital policy as evidenced by failure to document respiratory care for 2 of 5 patient's medical records reviewed (Patient #4 and #5).
Findings:
Review of the hospital's policy titled, "Oxygen Therapy Protocol" revealed in part: Scope - To all Respiratory Therapy Personnel. 2. A Physician's Order is generated as follows - Oxygen Therapy Protocol. 4. The therapy assessment form will be completed by the Respiratory Therapist on all referred as well as and admit assessment. The form will become a permanent part of the patient's chart. 8. The Respiratory Therapist will document the protocol in the Respiratory Services Progress Notes. 9. Pulse oximetry will be performed at least once each shift after setup to document continuing need for oxygen.
Review of Patient #4's Physician Orders revealed a Respiratory O2 Protocol order 12/14/22 6:00 p.m. Further review revealed an Initial Respiratory Assessment on 12/14/2022 at 23:59 but failed to reveal the additional required every shift assessments.
In an interview on 12/19/22 at 10:04 p.m., S1DON reviewed Patient #4's Medical Record and confirmed the required every shift Respiratory Assessments were not documented.
Review of Patient #5's Physician Orders revealed a Respiratory O2 Protocol order 12/14/2022 at 6:00 p.m. Further review of the Medical Record failed to reveal an Initial Respiratory Therapy Assessment and failed to reveal the Respiratory Therapist performed the required every 12 hour assessments prior to 12/16/222 at 3:10 p.m.
In an interview on 12/19/22 at 10:17 p.m., S1DON reviewed Patient #5's Medical Record and confirmed the Respiratory Assessments were not documented according to policy.
In an interview on 12/19/22 at 10:20 p.m. S2RT reviewed Patient #5's Medical Record and their respiratory binder and confirmed there was no initial assessment and no assessments documented every shift prior to 12/16/2022 at 3:10 p.m.