Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 010001	(X3) Date Survey Completed 08/11/2011
Name of Provider or Supplier Southeast Health Medical Center	Street Address, City, State 1108 Ross Clark Circle, Dothan, AL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.

(X4) ID Prefix Tag

Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)

A1163

RESPIRATORY SERVICES
CFR(s): 482.57(b)(3)

Services must only be provided under the orders of a qualified and licensed practitioner who is responsible for the care of the patient, acting within his or her scope of practice under State law, and who is authorized by the hospital's medical staff to order the services in accordance with hospital policies and procedures and State laws.

This STANDARD is not met as evidenced by:
Based on review of the facility's policies and procedures and medical records and interviews with the staff, it was determined the facility failed to ensure the respiratory department followed the physicians' orders for incentive spirometers in 3 of 3 closed records reviewed. This affect medical record (MR) #s 150488, 161816 and 62171. Findings include: Facility Policy Title: Incentive Breathing Policy: The Respiratory Therapist should utilize the following Incentive Breathing Protocol when a physician orders for Incentive Breathing. Purpose: The purpose of Incentive Breathing is to prevent or correct Pulmonary Atelectasis. Procedure 1. Non-Critical Care Patients a. Patient and family if possible should be educated and instructed on the use of the Incentive Breathing device and to obtain volume goals with each breath times 10 breaths each session. b. The patient should be instructed to perform these exercise sessions on his/her own at least four times a day if not more frequent and to always cough afterwards. Clinical Responsibilities: I. Respiratory Therapist should document the following with each Incentive Breathing treatment in the patient's medical record: Incentive Capacity achieved, number of times performed, breath sounds pre and post therapy, effective cough productive and non productive. Education should also be documented. II. The Respiratory Therapist should communicate goals and frequency of Incentive Breathing with the patient's nurse to include visual reminder posted in the patient's room. 1. MR # 150488 was admitted to the facility on 7/19/10 with diagnoses including Degenerative Joint Disease and underwent a Total Hip Replacement of the Right Hip on 7/19/10. Review of the Post-Op (Operative) Orders dated 7/19/10 revealed orders for an Incentive Spirometer q (every) 4 h (hours) while awake times 48 hours. Review of the Respiratory Therapy flowsheet dated 7/19/10 at 17:46 revealed documentation of the therapist using the Incentive Spirometer. There was no documentation of instruction on use every 4 hours with volume goals with each breath times 10 breaths each session and to always cough afterwards. An interview was conducted on 8/10/11 at 1:35 PM with Employee Identifier (EI) # 1, the Quality Outcomes Coordinator who verified the above. 2. MR # 161816 was admitted to the facility on 7/17/10 with diagnoses including Left Hip Fracture. Patient under went a Hip Replacement on 7/20/10. Review of the Post-Op (Operative) Orders dated 7/20/10 revealed orders for an Incentive Spirometer q4h while awake times 48 hours. Review of the Respiratory Therapy flowsheet dated 7/19/10 at 18:00 revealed documentation of the therapist using the Incentive Spirometer. There was no documentation of instruction on use every 4 hours with volume goals with each breath times 10 breaths each session and to always cough afterwards. Review of the Respiratory Therapy flowsheet dated 7/22/10 at 08:42 revealed documentation of the therapist using the Incentive Spirometer. There was no documentation of instruction on use every 4 hours with volume goals with each breath times 10 breaths each session and to always cough afterwards. There was no documentation of the use of an Incentive Spirometer between 7/19/10 at 18:00 and 7/22/10 at 08:42. An interview was conducted on 8/11/11 at 10:25 PM with EI # 1 who verified the above. 28969 3. MR # 62171 was admitted to the facility on 7/16/10 with diagnoses including Degenerative Joint Disease and under went a Right Total Knee Arthoplasty on 7/16/10. Review of the Post-Op Orders dated 7/16/10 revealed orders for an Incentive Spirometer q 4 h while awake times 48 hours. Review of the Respiratory Therapy flowsheet dated 7/16/10 at 16:40 revealed documentation of the therapist using the Incentive Spirometer. There was no documentation of instruction on use every 4 hours with volume goals with each breath times 10 breaths each session and to always cough afterwards. The patient was discharged on 7/19/10. There was no other documentation regarding the use of the incentive incentive spirometer during the patient's hospital stay. An interview was conducted on 8/10/11 at 1:35 PM with EI # 3, Registered Nurse (RN), Clinical Nurse Specialist, who verified the Incentive Spirometers had been the repsonsibility of Respiratory Services until April 2011 when it became the responsibility of Nursing Services. An interview was conducted on 8/11/11 at 10:25 AM with EI # 1, who verified the above findings.