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Based on record review and interviews, the hospital failed to meet the Condition of Participation for Nursing Services as evidenced by:

1) Failing to ensure a registered nurse supervised and evaluated the patient's nursing care by failing to have patient assessments performed by the RN for 2 of 4 patients reviewed for RN assessments (#2, #3) (see findings in Tag A0395);

2) Failing to ensure the patient's plan of care was implemented according to physician orders as evidenced by:
a) documentation in patient's medical records that medications were held and not administered according to physician's orders and not reported to the physician as to the reason for holding the medication for 2 of 6 patients reviewed for medication administration (#3, #5);
b) failing to obtain physician orders prior to administering medications for 1 of 6 patients reviewed for medication administration (#4);
c) medications not administered as ordered for 2 of 6 patients reviewed for medication administration (#4, #5);
d) failing to follow the hospital's policy and procedure relative to setting of telemetry monitor alarms in order to individualize the telemetry alarms specific to each patient's heart rate level and/or obtain physician's orders for parameters to set the telemetry monitor prior to placing a patient on a telemetry monitor for 8 of 8 patients reviewed for telemetry orders (#4, #5, #7, #8, #9, #10, #11, #12) (see findings in Tag A0396);

3) Failing to ensure the nurses assigned to provide care to a pediatric patient had been determined qualified and competent prior to their assignment. This was evident for 3 of 7 nurses reviewed who had been assigned to work on the unit with pedicatric patients (S3, S13, S14). (see findings in A397)


An Immediate jeopardy situation was identified on 02/09/10 at 1:00pm and reported to S1 Chief Executive Officer (CEO). The immediate jeopardy was a result of the hospital failing to ensure: 1) 4 of 8 patients on telemetry on 02/08/10 had physician orders for telemetry; 2) 8 of 8 patients on telemetry on 02/08/10 had physician orders that included patient-specific parameters for monitor settings; 3) patients on telemetry were monitored on the unit in which they were admitted as evidenced by telemetry monitors being placed on another unit of the hospital located greater than 155 feet away; and 4) the ICU (intensive care unit) nurses assigned to monitor the telemetry units and assigned the care of critical patients at a ratio of 1 nurse to 2 patients would be able to immediately attend to an alarming monitor by having 1 RN (registered nurse) responsible for 4 ICU patients and 6 telemetry monitors for 8 minutes on 02/05/10.

As the result of the hospital's action plan, the Immediate Jeopardy situation was removed on 02/10/10 at 5:35pm due to the hospital doing the following: 1) effective 02/09/10 the nursing policy "Continuous Cardiac Telemetry Monitoring" was revised to include a direct statement that all patients must have telemetry orders placed on each patient's chart; 2) unit shift report 02/10/10 included review of the policy revision, and all members who had not signed the acknowledgement of the revision in practice would review and sign the form prior to starting their assigned shift; the House Supervisor of each shift will monitor and ensure the completion of this process; 3) revised physician orders which included patient-specific parameters and the deletion of all range orders were placed on all patients on the Med/Surg unit who were being monitored by telemetry; 4) signatures were obtained from the Medical Executive Committee for their approval of the policy on 02/10/10; 5) phone conversation on 02/10/10 was held with the Chairman of the Hospital Board and S2 Chief Nursing Officer and witnessed by S5 Director of Critical Care Services and S15 Director of Surgery for approval of all actions taken; 6) a letter with the policy attached was e-mailed by S2 Chief Nursing Officer to all Medical Staff on 02/10/10 explaining the policy revisions, changes to the telemetry orders, and the relocation of the telemetry monitor; 7) monitoring for physician orders and patient-specific parameters will be performed on 100% (per cent) of the patients being monitored by telemetry on a daily basis for two weeks until compliance is consistently maintained, then monitoring will decrease to weekly until 100% compliance is consistently maintained for 3 consecutive quarters; 8) building services and biomedical department staff were activated to determine a means to provide direct visualization of the patient's waveforms at the Med/Surg unit nursing station, and power capability was completed 02/09/10; 9) a telemetry monitor was installed on the Med/Surg unit on 02/10/10 with the capability to view all patients on telemetry and alert visually by flashing any patient problem; 10) within the current month of February the vendor has committed to move the permanent telemetry monitor with audible alarms and strip running capability from ICU to the Med/Surg unit; 11) until the permanent telemetry monitor is moved, an ICU RN will remain assigned as a direct monitoring nurse who will be immediately available to respond to the telemetry patient, will alert ICU to print the patient's EKG (electrocardiogram) strip for specific time interval of noted patient concern, and communicate directly to the physician the patient's findings; 12) the ICU staff will print the patient's strips every 4 hours to be delivered to the monitoring nurse on the Med/Surg unit for placement on the patient's chart; 13) S5 Director of Critical Care Services will monitor this process for compliance on 100% of the patients being monitored by telemetry on a daily basis for two weeks until compliance is consistently maintained, then monitoring will decrease to weekly until 100% compliance is consistently maintained for 3 consecutive quarters; 14) ICU nurses with the competency to interpret arrhythmias were utilized in the formation of a 4-and-a-half week work schedule with the isolated role of telemetry monitoring on the Med/Surg unit which allowed for immediate response to any alarm and the competence to interpret the immediate needs of the patient; 15) scheduling assignments were communicated and implemented on 02/10/10; 16) permanent staffing schedule for monitoring will be ongoing until an alternate plan could be accomplished; 17) the long term plan was to educate and verify competency of RNs on the Med/Surg unit and to develop a new position for telemetry monitoring; 18) nursing leadership will develop and implement a job description for telemetry monitoring by 02/15/10.

The Immediate Jeopardy was removed and the hospital achieved compliance with the Condition for Nursing Services before the conclusion of the survey.

Based on record review and interview, the hospital failed to meet the Condition of Participation for Respiratory Services as evidenced by:

1) Failing to develop and implement a respiratory staffing system to enable the hospital to determine the number of respiratory staff that would be required daily to provide for the respiratory needs of the hospitalized patients and to allow for all respiratory treatments ordered by the physician to be followed. (Patients #4, #5) (see findings in Tag A1154 and Tag A1163)

2) Failing to obtain physician orders for ventilator settings for patient #4 who was on a ventilator. (see findings in Tag A1154)

3) Failing to ensure all respiratory treatments were provided as ordered by the physician for 2 of 6 patients reviewed for respiratory treatment administration (#4, #5)

4) Failing to ensure hospital policies and procedures were followed which required that all respiratory therapists were oriented and assessed for competency prior to performing patient care. This was evident for 1 of 3 respiratory therapists reviewed for orientation and competency (S18) (see findings in tag A1161)

An Immediate Jeopardy situation was identified on 02/09/10 at 1:00pm and reported to S1 Chief Executive Officer (CEO). The immediate jeopardy was a result of the hospital failing to ensure there was adequate numbers of respiratory staff on duty each day to meet the needs of patients by having 2 respiratory therapists (RT) to perform 24 respiratory treatments on the day shift and 14 treatments on the night shift of 02/09/10, while also providing the respiratory treatments for all patients admitted with oxygen/breathing and/or heart-related problems, performing EKGs (electrocardiograms), connecting patients to Holter monitors, bedside spirometry, nursery incentive spirometry on C-Sections three times a day, pulse oximetry checks every 8 hours for patients receiving oxygen, ABGs (arterial blood gases), and assisting with bronchoscopies in OR (operating room), which contributed to: 1) respiratory treatments not being administered as ordered, 2) treatments given more frequently than ordered without a physician's order, and 3) a patient on a ventilator being treated without physician orders for ventilator settings when transferred from OR to the ICU (intensive care unit).

As the result of the hospital's action plan, the Immediate Jeopardy situation was removed on 02/10/10 at 5:35pm due to the hospital implementing the following:

1) on 02/09/10 an addendum to the Scope of Care policy was developed by S18 Registered Respiratory Therapist Technical Supervisor and S23 Administrative Director of Respiratory Services to ensure appropriate staffing needs were assessed based on scheduled procedures as well as allowances for unscheduled events that must be absorbed into the workflow without disruption to the standard of care; on 02/10/10 the policy was reviewed and approved by the Medical Director of the Department and immediately placed into practice; S23 Administrative Director of Respiratory Services met with current shift staff and signatures of therapists were obtained regarding review and acknowledgement of the policy and procedure; on each shift a staff member will be assigned the responsibility for completing the staffing grid as noted by a mark on the staff schedule; an emergency staff meeting was held at 2:00pm on 02/10/10 to review the memo and policy with all staff; all respiratory staff signed a Record of Review acknowledging that they have read, reviewed, and understand the policy; adherence to the policy and stated staffing guidelines will be reviewed and documented by either S18 Technical Supervisor, S23 Administrative Director, or the House Supervisor daily for the next four weeks; once compliance is at 100% (per cent) consistently for four weeks, monitoring will be decreased to weekly;

2) on 02/09/10 a policy for acceptance and transcription of verbal orders was developed by S18 Technical Supervisor and S23 Administrative Director of Respiratory Services and approved by the Medical Director of the Department to ensure that respiratory therapists are performing treatments and procedures upon written order from a physician; on 02/09/10 a memo was sent to all respiratory staff enforcing the importance of the policy and procedures on how to write a phone or verbal order; an emergency staff meeting was held at 2:00pm on 02/10/10 to review the memo and policy with all staff; all respiratory staff signed a Record of Review acknowledging that they have read, reviewed and understand the policy; adherence to the policy will be monitored by chart audits daily for four weeks; once compliance is at 100% consistently for four weeks, then monitoring will be decreased to weekly;

3) on 02/09/10 a memo was developed by S18 Technical Supervisor and S23 Administrative Director of Respiratory Services to be sent to the Anesthesia staff including CRNAs (certified registered nurse anesthetists) and anesthesiologists informing them that an order must be written for a patient to be transferred from OR to ICU on a ventilator; on 02/10/10 at 10:00am, the memo was reviewed and discussed with the Director of Anesthesiology before distribution; on 02/10/10 at 11:00am the memo was distributed to all anesthesia staff with instructions to return the Record of Review form to S23 Administrative Director of Respiratory Services; S19 Director of Ancillary Services, S23 Administrative Director of Respiratory Services, or S15 Director of Surgery will inservice each CRNA and anesthesiologist regarding the change before the start of their next case; if the case is unscheduled, the House Supervisor will assure that the memo is reviewed and the CRNA/Anesthesiologist signed the Record of Review; the 4 House Supervisors were notified of this responsibility by S19 Director of Ancillary Services on 02/10/10; the memo and Record of Review form will be put on the clipboard in the evening after the surgery department has closed; all anesthesia staff education and signing of the Record of Review form will be completed by 02/26/10; adherence to this process will be monitored by daily chart reviews performed by S18 Technical Supervisor and S23 Administrative Director of Respiratory Services; once compliance is at 100% consistently for four weeks, audits will be decreased to weekly.

The Condition level deficiency is cited as an immediate jeopardy although the immediate jeopardy was removed and compliance with the COP was achieved before the conclusion of the survey.

Based on record review and interview, the hospital failed to ensure a registered nurse (RN) performed an initial patient assessment upon admit for 2 of 4 patients reviewed for RN assessments (#2, #3). Findings:

Patient #2
Review of Patient #2's medical record revealed she was admitted 02/02/10 as a direct admit at 12:14pm. Review of the "Patient Assessment Report" revealed no documented evidence Patient #2 was assessed upon admit by a RN. In a face-to-face interview on 02/08/10 at 10:30am, S3 Director of Med/Surg/OB (obstetrics) confirmed there was no documentation that Patient #2's admit assessment was performed by a RN.

Patient #3
Review of Patient #3's "Med-Surg Flowsheet" revealed no documented evidence a RN had reassessed Patient #3 every 24 hours per the hospital policies and procedures. In a face-to-face interview on 02/08/10 at 10:30am, S3 Director of Med/Surg/OB confirmed the above findings.

Review of the hospital policy titled "Assessment and Reassessment of Patients", last revised 03/09 and submitted by S2 Chief Nursing Officer as their current policy for nursing assessments, revealed, in part, "...2. Medical/Surgical Unit a. The initial physical assessment is completed by the RN within eight (8) hours of admission. b. Reassessment is performed every 24 hours or more frequently as indicated by the patient's condition. This reassessment is performed by an RN".

Based on record review and interview, the hospital failed to ensure the patient's plan of care was implemented according to physician orders by:
1) failing to administer or by holding an ordered medications without advising the patient's physician with the reason for holding or not administering the medication for 3 of 6 patients reviewed for medication administration (#3, #4, #5);
2) failing to obtain physician orders prior to administering medications for 1 of 6 patients reviewed for medication administration (#4);
3) failing to clarify specific orders for the administration of IV cardizem or evidence that a cardizem protocol had been approved by the medical staff. This was evident for 1 of 6 patients reviewed for medication administration (#4);
4) failing to obtain physician orders with patient-specific heart rate parameters for each patient placed on telemetry monitors for 8 of 8 patients reviewed for telemetry orders (#4, #5, #7, #8, #9, #10, #11, #12). Findings:

Medications held without report to physician:

Patient #3
Review of Patient #3's "Physician's Order" of 01/30/10 at 9:45am revealed an order to change Lopressor to 12.5 mg (milligrams) by mouth every 12 hours. Review of Patient #3's MAR (medication administration record) revealed Lopressor 12.5 mg was held on 01/30/10 at 2100 (9:00pm) with no documented evidence of the reason the Lopressor was held and that the physician was notified.

In a face-to-face interview on 02/05/10 at 1:15pm, S3 Director of Med/Surg/OB indicated the hospital had no policy and procedure for holding medications.

Patient #5
Review of Patient #5's "Physician's Order" of 02/05/10 at 8:05am revealed an order for Celebrex 200 mg by mouth every day. Review of Patient #5's MAR revealed 0900 (9:00am) was circled, indicating it was not given. Further review revealed no documented evidence of the reason Celebrex was held and that the physician was notified.

In a face-to-face interview on 02/08/10 at 11:30am, S3 Director of Med/Surg/OB confirmed there was no documented evidence in the nurse's notes why the Celebrex was not administered as ordered.

Review of the hospital policy titled "Medications", last revised 09/09 and submitted by S2 Chief Nursing Officer as the hospital's policy for medication administration, revealed, in part, "...If a patient cannot take medications at the time prescribed... Chart the reason the medication was not administered in the Nursing Progress Notes...". Further review revealed no documented evidence that the policy required the nurse to notify the physician when a medication was not administered as ordered.

Physician orders prior to administering medications:

Review of Patient #4's "Emergency Department Medication Administration Record" dated 01/27/10 revealed Regular Insulin was administered at 2250 (10:50pm). Review of the entire emergency room record revealed no documented evidence of a physician's order for insulin.
In a telephone interview on 02/05/10 at 10:05am, S5 Director of Critical Care Services indicated if the insulin protocol was used in the emergency department, the order would not be on the patient's record unless an insulin drip was ordered.

Review of the hospital's "Sliding Scale Insulin Protocol" submitted by S2 Chief Nursing Officer revealed, in part, "...Sliding Scale Insulin: Accucheck results minus 100 divided by 30 equals the number of units to administer subcutaneously...". Further review of the protocol revealed no documented evidence of the type of insulin to administer.

Medications not administered as ordered:

Patient #4
Review of Patient #4's "Physician's order" revealed an order on 01/31/10 at 0315 (3:15am) for Cardizem 10 mg IV (intravenous) now.
Review of Patient #4's MAR revealed no documented evidence Cardizem was administered as ordered at 3:15am on 01/31/10.
In a face-to-face interview on 02/05/10 at 12:40pm, S4 RN (registered nurse) confirmed there was no documented evidence in Patient #4's medical record that Cardizem was administered as ordered on 01/31/10 at 3:15am.

Patient #5
Review of Patient #5's "Physician's Order" of 02/05/10 at 8:05am revealed an order for Lasix 40 mg by mouth every day.
Review of Patient #5's MAR revealed no documented evidence Lasix was administered as ordered on 02/05/10.
In a face-to-face interview on 02/08/10 at 11:00am, S3 Director of Med/Surg/OB confirmed there was no documented evidence that Lasix had been administered as ordered.

Review of the hospital policy titled "Orders, Routine, Now and Stat", revised 02/09 and submitted by S2 Chief Nursing Officer as the current policy for medication administration, revealed, in part, "...Timed orders have increased importance over routine orders. Transcribe now orders and carry them out within 30 minutes of physician order...".

Review of the hospital policy titled "Medications", last revised 09/09 and submitted by S2 Chief Nursing Officer as the hospital's policy for medication administration, revealed, in part, "...C. Administration of medications ... 3. Prepare and give medications within the one (1) hour window...".

Protocols for medication administration:

Review of Patient #4's "Physician's Order" dated 01/31/10, with no documented evidence of the time the order was written, revealed an order to transfer to ICU (intensive care unit) and administer Cardizem drip if HR (heart rate) >115 (greater than) and titrate to rate of <100 (less than). Review of the entire medical record revealed no documented evidence of a Cardizem protocol with physician orders in writing and signed, dated, and timed by the physician.

In a face-to-face interview on 02/05/10 at 12:40pm, S4 RN indicated they had a protocol for Cardizem. Review of the form presented by S4 RN revealed no documented evidence of a protocol that had been approved by the medical staff.

Review of the hospital policy titled "Orders, Routine, Now and Stat", revised 02/09 and submitted by S2 Chief Nursing Officer as the current policy for medication administration, revealed, in part, "...Orders by protocol drugs may be administered per physician protocol only when such protocol have been approved by the medical staff. These orders are in writing and should be placed on the patient's chart and signed, dated, and timed by physician...".

Patient-specific parameters for telemetry: #4, #5, #7, #8, #9, #10, #11, #12

Review of Patients' #5, #8, #11, and #12 medical records revealed no documented evidence of a telemetry order with patient-specific parameters (including heart rate high limits, heart rate low limits, specific heart rate when treating hypotension, arrhythmias, or chest pain with Atropine) for telemetry monitoring.

Review of Patients' #4, #7, #9, and #10 medical records revealed telemetry orders with no documented evidence of patient-specific parameters (including heart rate high limits, heart rate low limits, specific heart rate when treating hypotension, arrhythmias, or chest pain with Atropine) for telemetry monitoring.

In a face-to-face interview on 02/08/10 at 11:40am, S10 ICU (intensive care unit) RN indicated all telemetry monitors were set at the standard default settings, and the default low heart rate was 50 and the default high heart rate was 150. She further indicated they did not receive physician orders for patient-specific parameters for telemetry settings. Interview with S10 ICU RN revealed that there were two alarms - one red which the RN could not change and a yellow alarm which the RN could change without requiring a physician's order. She further indicated the monitors in the ICU patient rooms showed if a telemetry monitor was alarming, but it did not indicate what the problem was, and the ICU nurse would need to go leave her patients and go to the monitor at the nursing station to interpret the telemetry strip. She further indicated the current ICU census was 4 patients, and there were 8 patients on telemetry monitoring.

In a face-to-face interview on 02/08/10 at 1:25pm, S11 RN confirmed there were no telemetry orders for Patients' #5, #8, #11, and #12.

Review of the hospital's "ECG (electrocardiogram) Monitoring" policy revealed the telemetry monitor alarms would be set within 20% (per cent) of the patient's heart rate.

In a face-to-face interview on 02/09/10 at 9:00am, S11 RN indicated the following patients' heart rates upon admit to the telemetry unit were as follows: Patient #4's heart rate 103 (20% = low 82, high 123); Patient #5's heart rate 72 (20% = low 57, high 86); Patient #7's heart rate 72 (20% = low 57, high 86); Patient #8's heart rate 80 (20% = low 64, high 96); Patient #9's heart rate 73 (20% = low 58, high 87); Patient #10's heart rate 63 (20% = low 50, high 75); Patient #11's heart rate 81 (20% = low 64, high 97); and Patient #12's heart rate 96 (20% = low 76, high 115).

Review of the hospital policy titled "ECG Monitoring", submitted 10/97 and presented by S2 Chief Nursing Officer as their current policy for telemetry monitoring, revealed, in part, "...All telemetry patients will have continuous ECG monitoring. ...Alarms will be set within 20% of patient's heart rate. Alarms will be on continuously...".

Based on record review and interview, the hospital failed to ensure the nurses assigned to provide care to a pediatric patient had been determined qualified and competent prior to their assignment. This was evident for 3 of 7 nurses reviewed who had been assigned to a pediatric patient. (S3, S13, S14). Findings:


Review of S3 Director of Med/Surg/OB's (obstetrics) personnel file revealed no documented evidence of pediatric training. In a face-to-face interview on 02/09/10 at 4:35pm, S15 Director of Surgery confirmed there was no documented evidence that S3 had completed the hospital training on providing pediatric care.

Review of S13 LPN's (licensed practical nurse) personnel file revealed no documented evidence of pediatric training. In a face-to-face interview on 02/09/10 at 4:35pm, S15 Director of Surgery indicated S13 was currently enrolled in the pediatric courses and had not completed the training prior to working on the pediatric unit.

Review of S14 RN's personnel file revealed no documented evidence of pediatric training.
In a face-to-face interview on 02/09/10 at 4:35pm, S15 Director of Surgery confirmed there was no evidence of pediatric training for S14 RN.

Based on observation, record review, and interview, the hospital failed to ensure that all physician verbal orders were recorded in the medical record according to hospital policy relative to documentation that the order was read back to the physician to ensure accurancy of the order. This was evident for 3 of 6 patient records reviewed for verbal order read-back verification (#1, #4, #R2). Findings:

Patient #1
Review of Patient #1's "Physician's Order" revealed a telephone order received 02/04/10 with no documented evidence of the time the order was received and no telephone order read-back verification.

Patient #4
Review of Patient #4's "Physician's Order" revealed a telephone order received 01/28/10 at 2030 (8:30pm) with no documented evidence of a read-back verification.

Patient #R2
Observation on 02/10/10 at 3:10pm revealed S20 RN Charge Nurse on the telephone at the Med/Surg/Telemetry nursing station receiving a telephone order for NT (nasotracheal suctioning) for Patient #R2. Further observation revealed S20 asking the physician if the order was prn (as needed) or one time only. There was no observation of S20 performing a read-back verification of the order received.

Review of the "Physician's Order" for Patient #R2 revealed a telephone order on 02/10/10 at 1515 (3:15pm) for "NT Suction pt (patient) prn respiratory distress v.o.r.b. (verbal order read back) name of Physician S21/name of S20 RN Charge Nurse".

In a face-to-face interview on 02/10/10 at 3:20pm, S20 RN Charge Nurse indicated she was trying to hurry to get an order to take care of Patient #R2. She confirmed she did not perform a telephone order read-back verification as she documented on the patient's physician's order sheet.

Review of the hospital's policy titled "Physician's Verbal and Phone Orders, Protocol For", last revised 09/09 and submitted by S2 Chief Nursing Officer as the hospital's current policy for verbal/telephone orders, revealed, in part, "...Any and all orders (verbal, phone) must be written on a Physician's Order Form. Orders are to be read back to the physician or health care practitioner giving the orders for accuracy and clarification. When writing the order, the nurse indicates as follows: ... 2) date, time, and VO or PO (verbal order or phone order) Physician name/read back Nurse name...".

Based on record review and interview, the hospital failed to develop a system to determine the numbers of respiratory therapists required on a daily basis in order to meet the respiratory care needs of the hospitalized patients and provide all respiratory treatments ordered by the physician. Findings:

Review of the respiratory staffing worksheet for 01/24/10 through 02/05/10 provided by S19 Director of Ancillary Services revealed that the amount of patients requiring respiratory therapy treatments was not considered when developing the number of therapists for each shift. The schedule revealed that all shifts were staffed by 2 respiratory therapists except the night shift on 01/25/10, 01/26/10, and 01/29/10. Further review revealed 01/25/10 and 01/26/10 had 1.75 respiratory therapists on the night shift and 1.5 on 01/29/10.

In the same face-to-face interview on 02/09/10 at 10:45am, S6 Certified Respiratory Therapist indicated additional duties (in addition to providing respiratory treatments) of the respiratory therapists included: 1) providing care for patients admitted with oxygen, asthma, breathing problems, and heart-related issues, 2) performing EKGs (electrocardiograms), 3) attaching holter monitors to patients, 4) performing smoking cessation teaching, 5) performing bedside spirometry, 6) performing nursery incentive spirometry on C-Sections three times a day, 7) performing pulse oxygen checks every 8 hours on patients receiving oxygen, 8) performing ABGs (arterial blood gases, 9) assist with bronchoscopies, and 10) assist with codes. She indicated that 80% (per cent) of the days a respiratory therapist could do everything as ordered by the physician.

In a face-to-face interview on 02/09/10 at 10:45am, S19 Director of Ancillary Services indicated when the respiratory treatments were completed on the night shift, the therapist was allowed to leave but remained on-call for the remainder of the shift. She confirmed there was not a system in place that was used to determine staffing requirements for respiratory therapist that was based on respiratory care needs and the acuity level of patients hospitalized that might require immediate respiratory therapy treatment and the number of treatments/procedures ordered for patients.

In a face-to-face interview on 02/09/10 at 11:00am, S22 Certified Respiratory Therapist presented a list of all respiratory treatments that were ordered for patients for 02/09/10. Review of the list revealed the following breakdown of treatments by hour: 8:00am - 10 treatments; 12:00pm - 5 treatments; 2:00pm - 3 treatments; 4:00pm - 6 treatments; 8:00pm - 8 treatments; 12:00am - 3 treatments; and 2:00am - 3 treatments. In addition, there was one bedside spirometry and 3 EKGs to be done.

Review of the hospital policy titled "Scope of Care", last revised 01/10 and submitted by S19 Director of Ancillary Services as their current policy on respiratory care staffing", revealed, in part, "...The department provides cardiopulmonary services for those patients identified with disease or abnormalities associated with the cardiopulmonary system, including patients with primary pulmonary diagnosis such as COPD (chronic pulmonary obstructive disease), asthma, or pneumonia as will as those patients whose primary diagnosis affects the pulmonary system. Respiratory support during emergencies is also provided. ... Respiratory support, and assistance is provided on an inpatient and outpatient bases. ... Staffing requirements are assessed on a shift basis as outlined by department policy. The routine staffing plan for the Cardiopulmonary Department requires two respiratory staff for the day and evening shift. The night shift requires one respiratory staff person with a backup on-call person to be available at all times. ... As patient needs change and/or service demand increases, additional personnel are assigned as needed by utilizing "extra-time", PRN (as needed) staff and/or "over-time" hours.

Based on record review and interview, the hospital failed to follow policies and procedures relative to orientation and assessment of competency for their respiratory therapy department personnel for 1 of 3 respiratory therapists reviewed for orientation and competency (S18). Findings:

Review of the hospital's policy titled "Competency Assessment", last reviewed 04/09 and submitted by S2 Chief Nursing Officer as the hospital's current policy for orientation and competency assessment, revealed, in part, "...Competency assessment of all new individuals will occur during the hiring process, orientation period, and on an ongoing basis. Competencies will be identified through a collaborative process, and assessed on a continuum including assessment during the pre-hire and hire processes, orientation period, and at least annually. Each department manager is responsible for assessing, maintaining, improving and monitoring staff competency based on established standards of practice. ... Initial competency assessment will include validation of: Core job functions (5-7 competencies that define "the essence" of that job), frequently -used functions and accountabilities, High-risk job functions and accountabilities, Age-specific/cultural/ethnic concepts for populations served To be completed within first three to six months of employment.

Review of S18 Registered Respiratory Therapist's (RRT) personnel file revealed a hire date of 03/30/09. Further review revealed no documented evidence of departmental orientation and an assessment of competency prior to performing her job duties.

In a face-to-face interview on 02/09/10 at 10:50am, S19 Director of Ancillary Services confirmed there was no documented evidence of orientation and competency for S18 RRT. She indicated the previous supervisor was responsible for S18's orientation, and he was released from the hospital as a result of duties not being performed, one of which was orientation and assessment of competency of S18 RRT.

Based on record review and interview, the hospital failed to ensure respiratory care services were provided as ordered by the physician for 2 of 6 patients reviewed for respiratory treatment administration. (#4, #5) Findings:

Patient #4

Review of Patient #4's "Physician's Order" revealed an order on 01/28/10 at 10:30am to give Albuterol via nebulizer every 8 hours. Further review revealed the Albuterol was ordered at an 8 hour frequency on 01/31/10 when Patient #4 was transferred to ICU and again on 02/01/10 when he was transferred from OR to ICU.
Review of the "RT (respiratory therapy) Treatment Flowsheet Detail" revealed the treatments were not performed as ordered from 1/28/10 to 2/5/10.

In a face-to-face interview on 02/05/10 at 1:10pm, S6 Certified Respiratory Therapist indicated the respiratory treatments were not administered as ordered by the physician.

Patient #4 was placed on a ventilator on 2/1/10 after going from the Operating Room to ICU. Review of Patient #4's "Physician's Order" revealed post-operative orders on 02/01/10 at 1:45pm with no evidence the physician ordered the ventilator settings for the patient. There was no documentation the Respiratory Therapist contacted the physician regarding the ventilator settings.

In a face-to-face interview on 02/05/10 at 1:10pm, S6 Certified Respiratory Therapist indicated there should be a ventilator protocol on Patient #4's medical record, and she confirmed there was no documented evidence of a physician's order that included ventilator settings.

In a face-to-face interview on 02/05/10 at 1:35pm, S7 RN (registered nurse) indicated the physician or anesthesiologist should have written orders for the ventilator that included the settings for the ventilator.

Review of the hospital's "Ventilator Physician Orders", submitted by S7 RN as the hospital's current ventilator orders, revealed, in part, "... Ventilator settings: Initial TV (tidal volume), Mode, Rate, FIO2, Peep, PS (pressure support)...", all with a space included for the practitioner to write in the settings requested.

Patient #5

Review of Patient #5's "Physician's Order" revealed an order on 02/05/10 for Atrovent/Xopenex nebs every 6 hours. Review of Patient #5's "RT Treatment Flowsheet Detail" revealed respiratory treatments were not administered as ordered from 2/5/10 to 2/8/10.

In a face-to-face interview on 02/08/10 at 11:20am, S9 Certified Respiratory Therapist confirmed the respiratory treatments were not administered as ordered by the physician.

Based on record review and interview, the hospital's nursing staff failed to administer all medications according to physician's orders, failed to advise the patient's physician when medications were held or not administered as ordered, failed to document in each patient's medical record the reason for holding or not administering the medication for 3 of 6 patients reviewed for medication administration (#3, #4, #5). Findings:

Patient #3

Review of Patient #3's "Physician's Order" of 01/30/10 at 9:45am revealed an order to change Lopressor to 12.5 mg (milligrams) by mouth every 12 hours. Review of Patient #3's MAR (medication administration record) revealed Lopressor 12.5 mg was held on 01/30/10 at 2100 (9:00pm) with no documented evidence of the reason the Lopressor was held and that the physician was notified.
In a face-to-face interview on 02/05/10 at 1:15pm, S3 Director of Med/Surg/OB indicated the hospital had no policy and procedure for holding medications.

Patient #4

Review of Patient #4's "Emergency Department Medication Administration Record" dated 01/27/10 revealed Regular Insulin was administered at 2250 (10:50pm). Review of the entire emergency room record revealed no documented evidence of a physician's order for insulin. In a telephone interview on 02/05/10 at 10:05am, S5 Director of Critical Care Services indicated if the insulin protocol was used in the emergency department, the order would not be on the patient's record unless an insulin drip was ordered.

Review of the hospital's "Sliding Scale Insulin Protocol" submitted by S2 Chief Nursing Officer revealed, in part, "...Sliding Scale Insulin: Accucheck results minus 100 divided by 30 equals the number of units to administer subcutaneously...". Further review of the protocol revealed no documented evidence of the type of insulin to administer.

Review of Patient #4's "Physician's order" revealed an order on 01/31/10 at 0315 (3:15am) for Cardizem 10 mg IV (intravenous) now. Review of Patient #4's MAR revealed no documented evidence Cardizem was administered as ordered at 3:15am on 01/31/10.
In a face-to-face interview on 02/05/10 at 12:40pm, S4 RN (registered nurse) confirmed there was no documented evidence in Patient #4's medical record that Cardizem was administered as ordered on 01/31/10 at 3:15am.

Review of Patient #4's "Physician's Order" dated 01/31/10, with no documented evidence of the time the order was written, revealed an order to transfer to ICU (intensive care unit) and administer Cardizem drip if HR (heart rate) >115 (greater than) and titrate to rate of <100 (less than). Review of the entire medical record revealed no documented evidence of a Cardizem protocol with physician orders in writing and signed, dated, and timed by the physician.

In a face-to-face interview on 02/05/10 at 12:40pm, S4 RN indicated they had a protocol for Cardizem. Review of the form presented by S4 RN revealed no documented evidence of a protocol that had been approved by the medical staff.

Review of the hospital policy titled "Orders, Routine, Now and Stat", revised 02/09 and submitted by S2 Chief Nursing Officer as the current policy for medication administration, revealed, in part, "...Orders by protocol drugs may be administered per physician protocol only when such protocol have been approved by the medical staff. These orders are in writing and should be placed on the patient's chart and signed, dated, and timed by physician...".

Patient #5

Review of Patient #5's "Physician's Order" of 02/05/10 at 8:05am revealed an order for Celebrex 200 mg by mouth every day. Review of Patient #5's MAR revealed 0900 (9:00am) was circled, indicating it was not given. Further review revealed no documented evidence of the reason Celebrex was held and that the physician was notified.
In a face-to-face interview on 02/08/10 at 11:30am, S3 Director of Med/Surg/OB confirmed there was no documented evidence in the nurse's notes why the Celebrex was not administered as ordered.

Review of the hospital policy titled "Medications", last revised 09/09 and submitted by S2 Chief Nursing Officer as the hospital's policy for medication administration, revealed, in part, "...If a patient cannot take medications at the time prescribed... Chart the reason the medication was not administered in the Nursing Progress Notes...".

Review of Patient #5's "Physician's Order" of 02/05/10 at 8:05am revealed an order for Lasix 40 mg by mouth every day.
Review of Patient #5's MAR revealed no documented evidence Lasix was administered as ordered on 02/05/10.
In a face-to-face interview on 02/08/10 at 11:00am, S3 Director of Med/Surg/OB confirmed there was no documented evidence that Lasix had been administered as ordered.

Review of the hospital policy titled "Orders, Routine, Now and Stat", revised 02/09 and submitted by S2 Chief Nursing Officer as the current policy for medication administration, revealed, in part, "...Timed orders have increased importance over routine orders. Transcribe now orders and carry them out within 30 minutes of physician order...".

Review of the hospital policy titled "Medications", last revised 09/09 and submitted by S2 Chief Nursing Officer as the hospital's policy for medication administration, revealed, in part, "...C. Administration of medications ... 3. Prepare and give medications within the one (1) hour window...".