HospitalInspections.org

Based on medical record review and staff interview, nursing staff failed to supervise and evaluate care by failing to flush a nephrostomy tube as ordered for 1 of 1 patients with a nephrostomy tube reviewed (Patient #3).

The findings included:

Medical record review, on 01/22/2019, revealed Patient #3, an 81-year-old, was admitted 12/06/2018 with diagnoses that included CVA (cerebral vascular accident - stroke) with craniectomy (surgical procedure to remove a part of the skull to reduce pressure on the brain) and aspiration pneumonia. Review revealed Patient #3 had a right nephrostomy tube. On 12/07/2018 at 0930, a physician order stated to flush the nephrostomy tube with 20 ml (milliliters) of normal saline (NS) every 12 hours and on 12/12/2019 the order was changed to flushing the nephrostomy tube with 10 ml NS every shift. Medical Record review failed to reveal evidence the nephrostomy tube was flushed as ordered on 12/08/2018, 12/09/2018, 12/10/2018, 12/11/2018, 12/15/2018, 12/17/2018, 12/18/2018, 12/19/2018, 12/22/2018, 12/25/2018 or 12/26/2018.

Staff interview with RN #2, on 01/24/2019 at 1515, revealed the hospital did not have a policy specific to nephrostomy tubes or flushing lines/tubes. Interview revealed no evidence the nephrostomy tube was being consistently flushed according to the order.

Based on hospital policy review, medical record review and staff interview, respiratory therapy staff failed to clarify a physician's order for Bipap settings before initiating non-invasive ventilation for for 2 of 3 patients (Patient #7 and Patient #1).

The findings included:

Review on 01/23/2019 of a policy titled "Non-Invasive Ventilation" issued 01/01/2016 revealed "...To provide non-invasive respiratory support to assist patients at risk for respiratory failure...Equipment: 1. BiPAP or CPAP (airway support administered through a facemask)...Procedure: 1. Verify physician's orders...Titration: 1. Initial patient settings if not given: IPAP: 10 EPAP: 5, FIO2: 50%..."

Open medical record review of Patient #7 on 01/23/2019 revealed a 73 year old admitted on 01/17/2019 for acute on chronic hypercabnic respiratory failure. Review of the "Admission Orders" dated 01/17/2019 revealed non-invasive ventilation and BiPAP were ordered at night. Further review revealed no initial settings for BiPAP were ordered. Review of the "NON-INVASIVE VENTILATOR FLOWSHEET" revealed Patient #7 was placed on BiPAP on 01/17/2019 at 2315. Review revealed the BiPAP settings were "...IPAP 14 EPAP 8, FIO2 35%." Review failed to reveal respiratory therapy clarified the physician's order prior to placing Patient #7 on the BiPAP and Patient #7 was not placed on the initial settings per policy.

Interview on 01/22/2019 with MD #1 (Medical Doctor), the respiratory director, revealed he usually ordered the BiPAP to be titrated per patient comfort. Interview revealed there should be admission BiPAP settings, and once those were ordered respiratory therapists could titrate per oxygen saturation. Interview revealed MD #1 was unsure if there was a BiPAP protocol.

Interview on 01/23/2019 at 1415 with RT #2 (Respiratory Therapy) revealed when the physician wrote admission orders they would write the initial BiPAP settings or write it on a physician order sheet. Interview revealed often times physicians would write an order to titrate the BiPAP per patient's comfort. Interview revealed if there were no admission settings, RT #1 would call the physician to get an update on the order. Interview revealed after reviewing Patient #7's chart there were no admission BiPAP settings for Patient #7 ordered.

Closed medical record review of Patient #1 on 01/22/2019 revealed a 77 year old admitted on 07/16/2018 for an acute exacerbation of COPD (chronic obstructive pulmonary disease). Review of the "Admission Orders" dated 07/16/2018 revealed oxygen was ordered. Review revealed BiPAP was ordered at night. Further review revealed no initial settings for BiPAP were ordered. Review revealed Patient #1 used oxygen via nasal cannula continuously until 07/20/2019. Review of the physician's orders on 07/20/2019 revealed "...Place patient on Bipap per RT protocol..." Review failed to reveal any respiratory therapy protocol in Patient #1's chart. Review of the "NON-INVASIVE VENTILATOR FLOWSHEET" on 07/20/2019 revealed Patient #1 was placed on BiPAP on 07/20/2018 at 0700. Review revealed the settings were "...IPAP: 14 EPAP: 7 FIO2: 60..." Review failed to reveal respiratory therapy clarified the physician's order prior to placing Patient #1 on the BiPAP and Patient #1 was not placed on the initial settings per policy.

Interview on 01/22/2019 with MD #1, the respiratory director, revealed he usually ordered the BiPAP to be titrated per patient comfort. Interview revealed there should be admission BiPAP settings, and once those were ordered respiratory therapists could titrate per oxygen saturation. Interview revealed MD #1 was unsure if there was a BiPAP protocol.

Interview on 01/22/2019 at 1520 with RT #3 revealed when the physician ordered bipap for a patient they would write the initial settings in the admission orders. Interview revealed if it was not written in the admission orders then they would sometimes write it on a separate physician order sheet. Interview revealed after reviewing Patient #1's chart there were no initial bipap settings ordered for Patient #1.