HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 3 patients' (Pt. #2) clinical records reviewed for turning and repositioning, the Hospital failed to ensure that the registered nurse supervised and evaluated the care for each patient by ensuring that turning and repositioning interventions were documented.

Findings include:

1. On 07/15/2021, the Hospital's policy titled, "Clinical Guideline for Pressure Injury" (dated 06/2019) was reviewed and included, "...Purpose ...establishes guidelines for the RN's (Registered Nurse) role in the prevention and treatment of pressure injuries ...Policy...5. Standard interventions for all patients ...c. Repositioning (minimum of Q2 )(every two) hours ...iii. Consideration for patients requiring Q1-Q2 turn and repositioning ...unable to turn and reposition self, poor nutrition ...poor cognition ..."

2. On 7/15/2021 the clinical record of Pt. #2 was reviewed. Pt. #2 was admitted on 04/30/2021 with diagnosis of severe encephalopathy (Disease that affects brain structure and function). The "Turning and Repositioning Flowsheets" from 05/01/2021 through 06/15/2021 were reviewed and lacked documentation that Pt. #2 was turned and repositioned every two hours on the following days:
- On 06/01/2021 from 6:32 AM to 8:00 PM (a total of 13 hours and 28 minutes)
- On 06/13/2021 from 6:29 AM to 11:31 AM (a total of 5 hours)
- On 06/14/2021 from 1:04 AM to 4:44 AM (a total of 3.5 hours)

3. On 07/15/2021 at approximately 12:45 PM, an interview was conducted with E #12 (Wound Care Nurse). E #12 stated that the facilities policy is to turn and reposition each patient every 2 hours, the patient should have been turned and repositioned.

Based on document review and staff interview it was determined that, the Hospital failed to ensure adequate respiratory staff were available in-house to provide respiratory care to all patients. This has the potential to affect all 40 airway management patients on census 05/03/2021.

Findings include:

1. On 07/14/2021, at approximately 2:45 PM, the Hospital's Respiratory Care Staffing Schedule from 04/03/2021 to 05/03/2021 (four weeks) was reviewed. The Respiratory Care Staffing Schedule included, on 05/03/2021 during the 7:00 AM - 7:00 PM shift there was one (1) Respiratory Therapist (RT) (E #2) on the Medical-Surgical/Telemetry Unit for eight (8) ventilator patients, one (1) tracheotomy patient, and four (4) nebulizer treatment. The four weeks Respiratory Care Daily Staffing Schedule indicated one -two RT staff shortage during both day and night shifts. The Respiratory Care Staffing schedule indicated, between 04/08/2021 - 04/12/2021 - there were a total of 43 airway management patients each day. The RT staffing schedule included, five (5) RTs during the day shift and four (4) RTs during the night shift. There was inadequate respiratory care staffing on all the units.

2. The Hospital's Respiratory Care Staffing policy was requested, the Director of Respiratory Care (E #5) was unable to provide policy for respiratory care staffing.

3. On 07/13/2021, at approximately 11:00 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted to 4th Floor - Medical/Surgical -Telemetry Unit on 03/10/2021 at 7:42 PM, with a diagnosis of ventilator support and tube feeding. Pt. #1 was transferred to (Outside Acute Care Hospital) on 05/03/2021 at 11:06 PM for post arrest evaluation. Pt. #1's clinical record included the following:

The respiratory care notes from 05/01/2021 - 05/03/2021 were reviewed. There were no respiratory care note on 5/3/21 from 6:33 AM to 1:36 PM to indicate that assessment and care had been completed. The respiratory care note documentation by Respiratory Therapist (E #2), dated 05/03/2021 at 1:36 PM, included, " ...ventilator settings ...nebulizer inhalation treatment not done ...cancel this execution ...ventilator care ...not done ...suctioning of airway ...not done ...ventilator alarm check complete ...Tech [technician] in attendance at 1:15 PM, rapid response called ...then changed to code blue ..."

4. On 07/13/2021, at approximately 1:00 PM, the Respiratory Care Therapist (E #2) was interviewed. E #2 stated that it was a busy day and she does not recall charting in the patient (Pt. #1's) clinical record. E #2 stated that she had to take care of 8 ventilator patients and one tracheotomy patient on the same day along with four nebulizer treatments. E #2 stated that she did not hear the ventilator alarm go off on the patient (Pt. #1). E #2 stated that while the code blue was called, she was in another room assisting another patient.

5. On 07/13/2021, at approximately 2:10 PM, the Director of Respiratory Care (E #5) was interviewed. E #5 stated that there is no policy related to respiratory care/therapist staffing. E #5 stated that they follow points system for RT staffing. E #5 stated that normally, one RT is assigned 6 airway management patients on any given day. E #5 stated that on 05/03/2021, there were 33 ventilators and 7 tracheotomy patients, which is a total of 40 airway management patients. E #5 stated that there were only 5 RTs during the day shift (7:00 AM - 7:00 PM) and only 4 RTs during the night shift (7:00 PM - 7:00 AM). E #5 stated that there should have been 6-7 RTs for 40 airway management, during the day shift. E #5 stated that there are seven (7) RT positions open since April 2020. E #5 stated that it has been difficult to find agency respiratory therapists. E #5 stated that currently, her staffing includes 6 full time RTs for the day shift and 13 full time RTs for the night shift.

6. On 07/15/2021, at approximately 9:30 AM, the Director of Respiratory Care (E #5) was interviewed. E #5 stated that she is working on putting together the staffing guidelines and/or policy for the Respiratory Therapists, since the Hospital does not have any policy related to it.