HospitalInspections.org

Based on document review and interview, it was determined for 1 of 3 (E #3) on call Respiratory Therapists for the Emergency Department, the Hospital failed to provide emergency care in accordance with acceptable standard of practice. As a result, the Condition of Participation 42 CFR 482.55, Emergency Services, was not met. This has the potential to affect 100% of the patients who utilize the Emergency Department.

Findings include:

1. The Hospital failed to ensure the integrated Respiratory services were available to be provided by qualified personnel.. Please see tag 1110.

Based on document review and interview, it was determined for 1 of 3 (E #3) Emergency Department (ED) respiratory therapists, the Hospital failed to ensure the integrated Respiratory services were available to be provided by qualified personnel. This has the potential to affect all ED patients that require emergent respiratory care.

Findings include:

1. The Respiratory Therapist schedule for July, August and September were reviewed on 09/27/2022 at 1:00 PM. The schedule indicated Emergency Department Licensed Practical Nurse (LPN) (E #3) was on-call 07/17/2022, 07/22/2022, 07/23/2022, 07/24/2022, 08/05/2022, 08/06/2022 and 08/07/2022.

2. Competency assessments for E #3 was reviewed on 09/27/2022 at approximately 2:30 PM. E #3 completed "Bipap Machine Set Up Competency" and "Ventilator Competency Assessment" on 07/01/2022.

3. The job description titled "Respiratory Care Practitioner" was reviewed on 09/28/2022 at 1:30 PM. The job description stated "Certifications, Licenses and Registrations Registered Respiratory Therapist (RRT) Required."

4. An interview was conducted with Operations Manager (E #2) on 09/28/2022 at approximately 2:00 PM. E #2 reviewed the on-call schedule. E #2 stated (E #3) is not a RRT, she is an LPN that has completed competencies."