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Based on record review and interview, the hospital failed to ensure each patient received care in a safe setting. This is deficient practice is evidenced by the hospital failed to ensure that personnel met the applicable standards (such as continuing education, certification or training) required by State or local law as evidenced by the absence of adolescent competency and PALs certification in the personnel files.
Findings:

Review of Medical Staff By-Laws last revised 10/01/2016 revealed in part: Scope of Service by patient type: (b) Ages of Patient: Adolescent, Adult, Geriatric.

Record review on 04/18/2024 at 9:05 a.m. revealed no evidence of adolescent competencies or PALS certification for 6(S2ICD, S6PCD, S7RN, S8RN, S9RN, S10RN) of 6 (S2ICD, S6PCD, S7RN, S8RN, S9RN, S10RN) RN personnel records reviewed.

In an interview on 04/18/2024 at 9:15 a.m., S1CNO stated that the RNs didn't have adolescent competencies or PALS certification. Furthermore verified that the Medical Staff By-Laws state that the scope of service includes adolescent aged patients.

Based on record review and interview, the hospital failed to ensure the Quality Assurance/Performance Improvement program measured, analyzed and tracked quality indicators to monitor the safety and effectiveness of respiratory services and quality of care. This deficient practice was evidenced by failing to review/revise respiratory policies/procedures to reflect current standards of practice.
Findings:

Review of hospital policies for Respiratory Services revealed the policies/procedures had not be reviewed since 08/2008 and revised since 02/2011.

In an interview on 04/18/2024 at 10:30 a.m. S1CNO verified that the 12 respiratory service policies had not been reviewed since 08/2008 or revised since 02/2011.

Based on record review and interview the hospital failed to ensure personnel were qualified to perform specific respiratory care procedures. This deficient practice was evidenced by failure to provide policies and procedures that included the qualifications, including job title, education, training and experience of personnel authorized to perform each type of respiratory care service and whether they may perform it without respiratory supervision.

Findings:

Review of hospital policies for Respiratory Services, provided by S1CNO as current, revealed they did not include the qualifications, education, training, and experience required of personnel authorized to perform each type of respiratory care service. Review of a policy title Wall Nebulizer did not include the above listed required items, or the job title of personnel authorized to deliver the therapy.

In an interview on 04/18/2024 at 1:00 p.m., S1CNO verified that nursing performs wall nebulizer treatments for patients and the only duty respiratory therapist performs is monthly ventilator checks. Furthermore S1CNO verifies policies failed to include the qualifications, education, training, and experience required of personnel authorized to perform each type of respiratory care service.