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Based on review of the definition of a licensed Respiratory Technician in the Iowa Code, policies, documents, job descriptions, open and closed medical records, and interview with staff, the critical access hospital (CAH) failed to ensure staff signing medical record documents used the appropriate abbreviation reflecting reflecting the staff member ' s educational background and professional licensure. The CAH administration instructed the Licensed Practical Nurses and Emergency Medical Technicians to document the abbreviation of RT behind their names following administration of a respiratory treatment. RT is a common abbreviation for Respiratory Therapist.

The CAH reported a census of 6 in-patients at the time of the complaint investigation. The surveyor identified concerns in 4 of 4 open medical records and in 9 of 9 closed medical records of current and former in-patients receiving respiratory treatments during hospitalization (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13).

Failure to assure staff used the accurate abbreviation reflecting their own specific educational background and professional licensure/certification following documentation of their names on a medical record, a legal document, places the CAH and the staff at risk for misinterpretation by reviewers of the medical records.

Findings included:

1. The Iowa Code: Chapter 152B Respiratory Care defines a respiratory therapy technician as "a person who has successfully completed a respiratory care education program for training therapists and has passed the certification examination for respiratory therapy technicians administered by the national board for respiratory care or a respiratory therapist technicians' licensure examination approved by the board."

2. A review of the CAH ' s 5/15/09 policy titled "Respiratory Therapy" revealed the following statement. "Respiratory Techs working in Respiratory therapy will have completed competencies as instructed by the contracted Respiratory Therapist".

A review of the CAH ' s Respiratory Technician job description, revised 1/09, revealed the following statement. "Education: high school diploma or equivalent required. Must have completed orientation and competencies in respiratory care."

A CAH memo to nurse managers, dated 1/29/09, identified Respiratory therapy changes: After training today with the [Respiratory Therapist Consultant], the following staff members have completed competencies for the Respiratory Technician job description. A list of staff names included in the memo. The memo also stated " When ever any of them complete the Resp [Respiratory] therapy flowsheet, they will enter their name with the designation of "RT" behind it.

A review of the job description for Emergency Room Technician (EMT), revised 4/09, revealed the following under Essential functions: "Administration of Respiratory Treatments".

A review of the undated job description for the Licensed Practical Nurse included the following statements: "Gives respiratory therapy treatments as ordered", "Gives respiratory therapy treatments and documents accordingly" and "Maintains accurate records".

3. Review of 4 open medical records showed the following information.

a. Patient #1 was admitted on 5/24/2010, after a motor vehicle accident with rib cage contusions. Physician orders, dated 5/24/2010, included Albuterol updrafts three times a day (TID). Respiratory notes, dated 5/24 through 6/2/10, showed respiratory treatments given by Staff C, a Licensed Practical Nurse (LPN); Staff B, a LPN; Staff D, a LPN; and Staff G, an Emergency Technician (EMT) entered the abbreviation RT (Respiratory Therapist/ Respiratory Technician) behind their names.
b. Patient #2 was admitted on 5/31/2010, due to hemoptysis (coughing up of blood or bloody sputum from the lungs or airway). Physician orders on 5/31/2010 included DuoNeb updrafts TID. Respiratory notes, dated 5/31 through 6/2/10, showed respiratory treatments given by Staff C, a LPN; Staff B, a LPN; and Staff H, a LPN but entered with the abbreviation RT behind their names.

c. Patient #3, admitted on 5/28/2010, due to bronchitis. Physician orders on 5/28/2010 included Albuterol updrafts TID. Respiratory notes, dated 5/28 through 6/2/10, showed respiratory treatments given by Staff C, LPN; Staff B, LPN; Staff D, LPN; Staff E, EMT; Staff I, EMT; and Staff G, EMT but documented with abbreviation RT behind their names on 5/31/2010 DuoNeb included updrafts TID. Respiratory notes dated 5/31 through 6/2/10 showed respiratory treatments given by Staff C, a LPN; Staff B; a LPN; and Staff H; a LPN but entered with abbreviation RT behind their names.
d. Patient #4, admitted on 5/31/2010, due to cellulitis. Physician order on 5/31/2010 noted DuoNeb updrafts TID. Respiratory notes dated 5/31 through 6/2/10 noted respiratory treatments given by Staff C, a LPN; Staff B, a LPN; and Staff H, a LPN but entered with initials RT behind their names.


4. A review of 9 closed medical records revealed the following:

a. Patient #5 was admitted on 3/10/10 and discharged on 3/13/10. Physician orders included Albuterol and DuoNeb updrafts treatments during Patient #5's hospital stay. Respiratory notes, dated 3/10 through 3/13/10, showed respiratory treatments given by Staff C, a LPN; Staff B, a LPN; Staff D, a LPN; Staff I, an EMT; and Staff F, an EMT-Certified Nurse Aid (CNA); but entered with abbreviation RT behind their names.
b. Patient #6 was admitted on 3/15/10 and discharged on 3/21/10. Physician orders included Albuterol and Pulmicort updrafts treatments during Patient #6's hospital stay. Respiratory notes dated 3/15 through 3/21/10 showed respiratory treatments given by Staff C, a LPN; Staff B, a LPN; Staff D, a LPN, Staff I, an EMT; and Staff G, an EMT; but entered with the abbreviation RT behind their names.
c. Patient #7 was admitted on 3/23/10 and discharged on 3/25/10. Physician orders included Albuterol updrafts treatments during Patient #7's hospital stay. Respiratory notes, dated 3/23 through 3/21/10, showed respiratory treatments given by Staff C, a LPN; Staff B, a LPN; Staff D, a LPN; and Staff E, an EMT; but documented with the abbreviation RT behind their name.
d. Patient #8 was admitted on 4/5/2010 and discharged on 4/6/10. Physician orders included Albuterol updrafts treatments during Patient #8's hospital stay. Respiratory notes, dated 4/5 through 4/6/10, showed respiratory treatments given by Staff C, a LPN; Staff B, a LPN; and Staff D, a LPN; but documented with the abbreviation RT behind their names.
e. Patient #9 was admitted on 4/7/2010 and discharged on 4/10/10. Physician orders included Albuterol updrafts treatments during Patient #9's hospital stay. Respiratory notes, dated 4/7 through 4/10/10, showed respiratory treatments given by Staff C, a LPN; Staff B, a LPN; and Staff D, a LPN; but documented with the abbreviation RT behind their names.
f. Patient #10 was admitted on 4/19/2010 and discharged on 4/21/10. Physician orders included Albuterol updrafts treatments during Patient #10's hospital stay. Respiratory notes, dated 4/9 through 4/21/10, showed respiratory treatments given by Staff C, a LPN; Staff B, a LPN; and Staff D, a LPN,
g. Patient #11 was admitted on 4/23/2010 and discharged on 4/27/10. Physician orders included Albuterol updrafts treatments during Patient #11's hospital stay. Respiratory notes, dated 4/23 through 4/27/10, showed respiratory treatments given by Staff C, a LPN; Staff B, a LPN; Staff D, a LPN; Staff E, an EMT; Staff F, an EMT; and Staff I, an EMT; but documented with the abbreviation RT behind their names.
h. Patient #12 was admitted on 4/26/2010 and discharged on 4/30/10. Physician orders included Albuterol updrafts treatments during Patient #12's hospital stay. Respiratory notes, dated 4/26 through 4/30/10, showed respiratory treatments given by Staff C, a LPN; Staff B, a LPN; and Staff D, a LPN; but documented with the abbreviation RT behind their names.
i. Patient #13 was admitted on 5/26/2010 and discharged on 5/28/10. Physician orders included PRN (as needed) DuoNeb updrafts treatments for Patient #13. Respiratory notes, dated 5/26 through 5/28/10, showed three respiratory treatments given by Staff B, LPN; Staff D, a LPN; and Staff G, an EMT but documented with the abbreviation RT behind their name.

4. A review of the personnel files revealed Staff B, a LPN; Staff C, a LPN; Staff H, a LPN; and Staff I, an EMT; lacked evidence of a competency evaluation by the Respiratory Therapist per hospital policy. Staff B, a LPN; Staff C, a LPN; Staff D, a LPN; Staff E, an EMT; Staff F, an EMT; Staff G, an EMT; Staff H, a LPN; and Staff I, an EMT lacked evidence of completion a respiratory care education program and the certification examination for respiratory therapy technicians as defined in Iowa Code 152B.

5. Staff interviews revealed the following.

a. On 6/1/2010 at 12:10 PM, Staff A, a LPN, stated the LPNs and EMTs were responsible for respiratory treatments. Staff A confirmed the LPNs and EMTs were instructed to sign off the respiratory treatments and place RT behind their name. Staff A stated, "The RT stands for Respiratory Therapist. I was told to sign RT after my name when I did respiratory treatments. I don't know why, I'm not a Respiratory Therapist. At first it bothered me sign the RT, but now I just do it, it doesn't bother me anymore".
b. On 6/2/10 at 8:45 AM, Staff G, an EMT, stated respiratory therapy for in-patients would be one of his/her duties. Staff G stated prior to doing any updrafts the Respiratory Therapist Consultant trained staff on the procedure. Staff G stated after the treatment is completed, he/she signs off on the respiratory flowsheet with RT, this means Respiratory Technician. Staff G stated instructions to sign RT were given at orientation.
c. On 6/2/10 at 11:55 AM, Staff J, Nurse Information Coordinator, stated his/her understanding of the Respiratory Technician issue dealt with billing. Staff J stated if a Registered Nurse (RN) does the respiratory treatment, this service isn't charged for because it is considered part of the nursing care. Staff J reported when the Respiratory Therapist Consultant conducted the last training, Staff B did not attend due to family issues. Staff J confirmed Staff C's competency evaluation lacked a signature by the Respiratory Therapist Consultant and Staff I's competency evaluation was documented by the Chief Nursing Officer (CNO).
d. On 6/2/10 at 12:30 PM, the Chief Nursing Officer (CNO) stated our Respiratory Therapist Consultant trains our LPNs and EMTs as Respiratory Technicians. The staff go through a competency check list with the Respiratory Therapist Consultant, then they are able to sign respiratory treatments as a RT, Respiratory Technician. When a Registered Nurse (RN) does the Respiratory treatment the hospital cannot charge for this service, it is considered part of the room charge. If the Respiratory Technician does the treatment we can bill for this service.
It is our standard practice that once the staff is trained as a Respiratory Technician and they administer the respiratory treatment they are to sign RT as the Respiratory Technician.A few years ago we did send 2 staff to Respiratory Technician training, but they did not pass the examination. I was not aware of the Iowa Code 152B requirements for a Respiratory Technician, our Respiratory Therapist Consultant advised us of the procedure we use.