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WEST PENN HOSPITAL
RESPIRATORY CARE SERVICES POLICIES
Tag No.: A1160
Based on a review of facility policies and documents and medical records (MR) and interview with staff (EMP), it was determined that the facility failed to provide medical staff directives specific to 'Covid 19 - Manual Pronation' to ensure safety practices were being followed for one medical record reviewed (MR1).
Finding include:
A review of the facility's "Covid 19- Manual Pronation" policy, dated April 1, 2020, failed to outline the responsibilities of the Respiratory Therapist during Manual Pronation which include being the care team member responsible for the count.
A review of MR1 revealed that the patient was admitted on September 12, 2021, with a diagnosis of Covid-19. Further review revealed that the patient was being turned to the prone position by the care team when the endotracheal securement device was not in place. Furthermore, the medical record revealed that the patient suffered a hypoxia inducted cardiac arrest secondary to the endotracheal tube dislodgement.
A review of a facility document dated November 8, 2021, revealed that physician EMP12 acknowledged being outside of the room observing at the time of the event and from EMP 12's perspective, there was a breakdown in communication between the team - nursing and Respiratory prior to the Manual Pronation. Additionally, according to the document, the feedback that EMP12 received from the Respiratory Therapist after event was that the volume of secretion increased and likelihood the adhesive from the headgear would be ineffective. Further review of the document revealed that EMP12 debriefed with the nursing staff who expressed that the count was missed and they did not feel comfortable with the therapist as this was a newer relationship.
During an interview with EMP1 on November 10, 2021, at 2:00 PM, it was confirmed that the Covid 19 Manual Pronation policy did not specify that the Respiratory Therapist was responsible for the count. EMP1 also stated that the Covid 19 - Manual Pronation policy was in the process of being updated to ensure safety practices were being followed by all staff.