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Based on review of facility documentation and staff interview (EMP), it was determined the facility failed to ensure the respiratory therapy department developed policies and procedures for bedside bronchoscopy procedures and temporary practice permits for new employees.

Findings include:

On October 11, 2022, a review of the Respiratory Department's policies and procedures was completed.

1. The Respiratory Department policies did not include a policy or procedure for bedside bronchoscopy.

On October 11, 2022, a review of the facility document, "Respiratory Care Scope of Practice," last revised November 2018, revealed, "The responsibilities of a respiratory therapist include, but are not limited to:...3. Application of therapeutics to respiratory care...d. Artificial airway insertion, management, and care. e. Airway clearance."

During an interview on October 11, 2022, at 12:45PM, EMP 6 described the respiratory therapists' (RTs') role with the bedside bronchoscopy procedures done in the ICU. "Both nurses and RTs do inline suction, the only type used for vented patients...RTs have done mucous retrieval in ICU with EMP 5 on site...RTs use bronchoscope to suction."

Further interview with EMP 6 revealed that RTs uncommonly provide airway management via endotracheal tube with EMP 5 looking at camera while RT advances bronchoscope. EMP6 stated the objective of having the RTs perform the bronchoscopy is to "free up the physician." When asked if this procedure is in the RT's scope of practice, EMP6 confirmed, "Airway management is in our scope of practice."

During an interview on October 11, 2022, at 1:20 PM, EMP7 revealed that the disposable bronchoscope plugs into the glidescope and RTs will advance the scope under the observation of EMP5. EMP7 described that this is done only for secretion management, and if a "diagnostic bronchoscopy" is performed, the RT role is to be a pair of "second hands."

Further interview with EMP7 confirmed he is unaware of a facility bedside bronchoscopy policy. EMP7 stated he was unsure of the specific competencies required, and specific documentation required by the RT after assisting/providing this service.

During an interview on October 11, 2022, at 2:50 PM, EMP4 confirmed the Respiratory Department does not have a policy/procedure for the RT role in bedside bronchoscopy. Further interview confirmed there is no process for ensuring competencies or providing training to RTs other than learning from EMP5.


2. On October 12, 2022, review of HR policy, "Licensure, Certification, Registration, and Verification for Employees and NonEmployees", last revised date unknown, revealed that it did not address those working on a temporary license.

On October 11, 2022, at 10:00am, interview with EMP4 took place. At this time EMP4 explained that the hospital will hire certified respiratory therapists, new grads working on a temporary license, and registered respiratory therapists, but that if they are not already a registered respiratory therapist that they need to obtain their license as a registered respiratory therapist within one year of hire. When asked further about a temporary license, EMP4 admits that they imagine it would expire if the therapist taking their test fails, but they cannot say for certain. EMP4 was able to explain that for certain, within the hospital, that if a therapist ' s temporary license expires at the end of the year, they will be removed from the schedule and eventually terminated if the therapist fails to sit and pass their exams.

On October 12, 2022, at 9:43am, interview with EMP9, revealed that there is nothing from HR that outlines the scope of a respiratory therapist working on a temporary practice permit. There is also nothing that regulates or governs those working on one. EMP9, states they also reached out to the respiratory therapy department specifically, and they do not have one either.