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Based on interview and record review, the hospital failed to ensure adequate numbers of qualified RTs and other personnel during the night shift of 6/14/25, according to the Respiratory Therapyst's Staffing Plan. This failure had the potential to compromise the patient care and treatment,

Findings:

On 7/8/25 at 1304 hours, an interview was conducted with the Director of Regulatory Affairs, Director Respiratory Services, and Manager 3. Manager 3 stated on 6/14/25, for the night shift (7 pm to 7 am), they had 26 RTs scheduled. Two hours prior to the start of the shift, six RTs called in sick. The backup plan for the needed RTs for 12-hour night shift was to ask for the day shift RT staff for volunteers to stay over for four hours and utilize the RTs who were scheduled but did not take patients, including two off-unit resources, two breakers, and the RTs assigned to L&D unit who were reassigned to the NICU with workload instead. The NICU CRCP was assigned to deliveries (L&D 1) and assisted in two deliveries before 0130 hours. The night RCP Educator worked that night to take over the PICU/CVICU Charge. The RCP Team Lead was the house supervisor of the hospital's RT.

Review of the NOC Shift Assignment Sheet dated 6/14/25, was conducted with the Director of Regulatory Affairs, Manager 3, and the Director of Respiratory Services. The NOC Shift Assignment showed a Team Lead; Breaker 1 and 2, Resource, and L&D 1 were blank. The Director of Respiratory Services and Manager 3 stated two RTs stayed over from the day shift (7am to 7pm) to work four hours for the night shift. One RT left at 2340 hours, on 6/14/25, and one RT left at 0216 hours on 6/15/25. The RCP Educator was the CRCP of the PICU/CVICU and left at 0300 hours, on 6/15/25. The NICU CRCP took over the patient assignment for one RT and also had L&D 1. The Team Lead took over the CRCP of NICU and the PICU/CVICU. The Director of Respiratory Services and Manager 3 were unable to answer who took the other RT's workload assignment.

Review of the L&D deliveries for the night shift of 6/14/25, showed one delivery at 2242 hours and another at 0109 hours. Manager 3 and the Director of Respiratory Services stated another RT covered the patients assigned to L&D 1 in the NICU while L&D 1 attended the deliveries. They could not provide documentation on the RT assignment sheet showing patient coverage for L&D 1 during the deliveries.

Manager 3 and the Director of Respiratory Services confirmed that the Team Lead (RT House Supervisor) took on the role of CRCP for both the NICU and PICU/CVICU. They stated they dissolved some of the patient workload by 2300 hours and distributed the patients to other RTs after the second RT left at midnight. They could not provide documented evidence of the RT's patient assignment after the second RT left.

Review of the Hospital's Plan for the Delivery of Care (Scope of Services) Patient care Department: Respiratory and Pulmonary Services, undated, showed the Respiratory Services uses an acuity-based model of staffing levels and measured productivity. RVUs based on validated procedural time standards are used for all areas as a monitor to schedule an adequate number of therapists for the ordered workload. Staffing is adjusted throughout the shift to meet changes in the acuity and census of the units. Respiratory Services has a staffing standards of RCPs, a Unit Charge RCP per assigned unit, and a House or relief Lead RCP. Patient assignments are based on an acuity system. One RVU equals 10 minutes. Each procedure is time weighted toprovide appropriate time management for the assigned practitioners. This provides the RCP with time enough to validate the order, deliver the treatment, per or post patient assessment, and document. This allows for fleile staffing response which adjusts to changes in the number of procedures or acuity of the patients. RVU Staffing Guideline: The Respiratory Services Staffing Guideline is a guide for staffing and workload decisions, in alignment with staffing regulations and recommendations. In response to changes in acuity, volume, or another system challenges, Respiratory Care leaders may utilize discretion and judgement when adjusting staffing decision outside of these guidelines.

- Based on the total number of RVUs.
- Average workload is 60 RVUs per RCP.
- Unit Charge should be assigned 18 to 24 RVUs as necessary.
- ED RCP staffing is adjusted based on the ED patient volumes.

Staffing Guidelines for Inpatient Units:
- 1 RCP: 40 to 45 RVUs
- 1 RCP + 1 UL (Unit Lead): Less than 84 RVUs
- 2 RCPs + 1 UL: 85 to 144 RVUs
- 3 RCPs + 1 UL: 145 to 204 RVUs
- 4 RCPs + 1 UL: 205 to 264 RVUs
- 5 RCPs + 1 UL: 265 to 324 RVUs
- 6 RCPs + 1 UL: 325 to 384 RVUs

Contingency Plan:
- Refer to the P&P when demand for services exceeds the supply of RCPs.

Review of the RCP and RVUs on 6/14/25, for the Night Shift:
- Total for NICU (4 South and Small Baby units): 392 RVUs (3920 minutes).
- RT A: 64 RVUs (640 minutes)
- RT B: 60 RVUs (600 minutes)
- RT C: 75 RVUs (750 minutes)
- RT D: 61 RVUs (610 minutes)
- RT E: 59 RVUs (590 minutes)
- RT F: 64 RVUs (640 minutes)
- RT Lead: 16 RVUs (160 minutes)

The Director of Respiratory Services and Manager 3 discussed the assigned RVUs of the RCPs in the NICU. The Director of Respiratory Services stated the RVU was the calculated time RT spent with the patient, including the number of treatments, patient care assignments, and workload. The target goal average would be 600 minutes (60 RVU) per shift. The workload dropped after 2300 hours, for example, the BID treatments. The Director of Respiratory Services and Manager 3 could not show the patient reassignment and recalculation of the RVU after 2300 hours for the NICU to show the workload had dropped to less than 392 RVU.

On 7/9/25 at 1300 hours, an interview and record reviews were conducted with the Director of Respiratory Services, RT Educator, and the Director of Regulatory Affairs. The Director of Respiratory Services stated they were not short of staff, she was not called, and they did not need to use the Contingency Plan. There were no free L&Ds 1 and 2, the RTs assigned to the L&D did not have deliveries after 0130 hours. The RTs had a good team, they worked together, other RTs would cover if the L&D RTs were called for deliveries.

On 7/9/25 at 1700 hours, a telephone interview was conducted with the RCP Team Lead. The RCP Team Lead stated they were able to recruit the RTs from the day shift. The Team Lead stated the day shift Team Lead should notify the manager for the night shift staffing. For the RT staffing after the recruited RTs and the RT Educator left after midnight, the Team Lead stated he took over the NICU and PICU/CVICU Charge RCP and acted as a resource; the PICU was also busy, he helped with the critical patient, transported the patient to CT scan, and figured out the staffing for the next shift. They were able to dissolve tasks for the one RT workload and were able to distribute the patients when the RTs left. For where it would show what tasks were dissolved and the patient reassignment, the Team Lead stated the Unit Lead would track who would get the patient; and the tracking was not recorded and was discarded at the end of the shift. The Team Lead stated the RT staffing was short when the RTs left and he used the contingency plan.

On 7/10/25 at 1130 hours, a review of the PICU/CVICU's RVUs for 6/14/25 at 1951 hours, was conducted with Manager 3. The total RVUs were 481 (over 97 RVUs). Manager 3 stated the RVUs were recalculated after 2300 hours (over 80 RVUs), but the recalculation was undated and lacked a specific time. The RT and RVUs were as follows:
- RT G: 66 RVUs (660 minutes); 58 RVUs (580 minutes)
- RT H: 74 RVUs (740 minutes); 66 RVUs (660 minutes)
- RT I: 70 RVUs (700 minutes); 69 RVUs (690 minutes)
- RT J: 68 RVUs (680 minutes); 68 RVUs (680 minutes)
- RT K: 68 RVUs (680 minutes)
- RT L: 66 RVUs (660 minutes)
- RT AM: 69 RVUs (690 minutes)

Manager 3 verified the total RVU for PICU/CVICU was 481 (over 97 RVUs) at 1951 hours. The recalculated RVU was 464 (over 80 RVUs).

On 7/10/25 at 0908 hours, the RCP staffing concern was shared with the Director of Regulatory Affairs and Manager 3. The RT Educator left at 0200 hours.

Based on interview and record review the hospital failed to ensure the patient's medical record for intubation procedures were completed for three of eight sampled patients (Patients 2, 3 and 4). This posed an increased risk of substandard healthcare outcomes to the patients.

Findings:

Review of the hospital's Medical Staff Rules and Regulations dated 10/2021 showed the following:

Responsibility for the Record: The patient's Attending Practitioner and each practitioner involved in the care of the patient shall be responsible for preparing a complete and legible medical record for each patient.

Progress Note: The date and time of the Progress Note shall be entered by the Attending Physician who is familiar with the patient, and more often when warranted by the patient's condition, when there is a significant change in the patient's status, or following a procedure performed by the physician. This is in addition to any progress notes written by the residents. The Progress Note should provide a chronological picture of the patient's progress and be sufficient to permit continuity of care and transferability. The Progress Note should delineate the course and results of the treatment.

1. On 7/8/25 at 1534 hours, Patient 2's medical record was reviewed with the Director of Regulatory Affairs, Director of Respiratory Services, and Manager 3. Patient 2's medical record showed Patient 2 was admitted to the hospital on 3/3/25, for cardiology and pulmonary consultation.

Review of the RT's documentation dated 6/15/25 at 0009 hours, showed the RT assisted the physician with ETT intubation, and Patient 2 was orally intubated.

Review of the NICU Progress Notes for Patient 2's ETT Intubation Procedure did not show the Procedure Note for the Endotracheal Intubation performed on 6/15/25 at 0009 hours.

Review of the NICU Progress Note dated 6/15/25 at 0926 hours, prepared by Physician 1, showed the following:
- Respiratory support: ventilation from 6/15/25, FIO2 0.5 to 0.6, RR 35, PIP 24 cm H2O, Peep 8 cm H2O, PS 10 cm H2O, Mode: SIMV.
- Current Problems and Diagnosis: Respiratory failure on 6/15/25 at 2350 hours, ETT intubation, the patient was intubated for respiratory failure with 3.5 ETT on the 4th attempt. - Confirmed with pedicap, good O2 saturation level, and pending chest x-ray.
- Plans: Intubated on 6/15/25, due to increased breathing work (IWOB) and FIO2 requirement. Currently on SIMV/PS 24/8, PS 10, x 35, FIO2 50-60%.

Review of the previous ETT Intubation Note for Patient 2 dated 6/6/25 at 1541 hours, showed the following sections were not completed:
- Indication
- Consent
- Premedication: list of medication names (physician's preference), see MAR for doses and sequence.
- Procedure: after preoxygenation, cords were visualized by laryngoscopy, type of blade used, type of ETT (cuffed/uncuffed) used, route (oral or nasal).
- Confirmation of placement: list of types/ways ETT placement confirmation.
- Complications
- Name of the physician who performed the procedure, time & date.

The Director of Regulatory Affairs was asked to show the Procedure Note for Patient 2's ETT intubation details on 6/15/25 at 0009 hours, when the physician attempted 4 times before the patient was intubated and sedation used if it was needed. The Director of Regulatory Affairs could not show documentation of Patient 2's ETT intubation Procedure Note on 6/15/25 at 0009 hours. The Director of Respiratory added to look at the MAR to find the medication used for sedation.


2. On 7/8/25 at 1540 hours, Patient 3's medical record was reviewed with the Director of Regulatory Affairs, Manager 3 and the Director of Respiratory Services. Patient 3 was admitted to the hospital's NICU on 6/14/25 at 1909 hours, and was intubated at 2113 hours.

On 7/9/25 at 1308 hours, review of Patient 3's medical record was conducted with the RCP Educator, Director of Regulatory Affairs, and the Director of Respiratory Services. Patient 3 was placed on CPAP at Hospital B's L&D and was intubated on 6/14/25 at the hospital's NICU by a neonatologist.

Review of Patient 3's H&P examination created on 6/15/25 at 0106 hours, showed the following:

Patient 3 was admitted immediately following delivery at Hospital B for prematurity and respiratory failure. Current problems and diagnoses: Respiratory failure less than 28 days old. Onset date was 6/14/25. Respiratory support in the delivery room consisted of PPV (Positive Pressure Ventilation) and CPAP (Continuous Positive Airway Pressure) + 6. Admitted to the NICU on CPAP + 6, FIO2 30%. The infant was intubated, and after intubation, the FIO2 improved from 40% to 21%.

The RCP Educator stated he could not find the Procedure Note for Patient 3's ETT intubation for 6/14/25.


3. On 7/8/25 at 1535 hours, Patient 4's medical record was reviewed with the Director of Regulatory Affairs, Manager 3 and the Director of Respiratory Services.

Patient 4 was admitted to the hospital's NICU on 6/14/25 at 1908 hours. Patient 4 was intubated at 2148 hours. Patient 4 was placed on CPAP at Hospital B's L&D and was orally intubated on 6/14/25, at the hospital's NICU by a neonatologist.

Review of Patient 4's H&P examination created on 6/15/25 at 0126 hours, showed under the section of Birth, the baby was transferred to the Hospital's NICU, on CPAP, immediately following the delivery, on ventilator support.

The section for Current Problems and diagnosis showed Respiratory failure less than 28 days old. Onset day was 6/14/25. Under the comments section showed respiratory support in delivery room consisting of PPV (Positive Pressure Ventilation) and CPAP (Continuous Positive Airway Pressure) + 6. Due to increased FIO2 requirement, the infant was intubated and given surfactant ... Plan: Intubate for surfactant administration and increase CO2. Continue SIMV wean as tolerated.

The RCP Educator stated the intubation documentation was in the progress note, it was an emergent intubation.

On 7/9/25 at 1315 hours a telephone interview was conducted with the NICU Medical Director, Director of Regulatory Affairs and Manager 3. The NICU Medical Director stated the Procedure Note should be documented on the patient's Electronic Medical Record. The documentation would be exported as a separate procedural note, sometimes when exported would glitch to the progress note. The procedure was documented on the procedure note or the neonatal. It showed a Procedure Note as the heading. Complication, number of attempts, and abnormal findings should be detailed in the documentation. The Attending physician or the Fellow could intubate the patient.

The findings were shared with the Director of Regulatory Affairs, RCP Educator, and the Director of Respiratory Services.