HospitalInspections.org

Based on interview and review of the facility's quality assurance and performance improvement committee meeting minutes, the facility failed to ensure the scope and complexity of the respiratory therapy department's activities are monitored by the facility's quality assurance and performance improvement committee meeting minutes. This has the potential to affect all patients receiving respiratory therapy services. The facility's census was 251 patients.

Findings include:


On 12/21/11 at 4:00 P.M. in an interview with the Director of Respiratory Therapy he/she said that his/her department has improvement projects they work on. Among them, he/she said, are the number of successful rates of intubation for each respiratory therapist, the average number of days patients are on ventilators, and the rate of self-extubation rates.

During the interview he/she presented a medical intensive care unit respiratory report. The report was reviewed. The report stated for the first quarter of 2011 the unit had 4.63 average ventilator days per patient, 4.43 average ventilator days per patient, and 4.73 average ventilator days per patient. In the interview, the Director of Respiratory Therapy stated the goal was to have 4.5 average ventilator days per patient.

On 12/21/11 a review of the facility's quality assurance and performance improvement committee meeting minutes for 2011 was reviewed. The minutes revealed discussion of ventilator acquired pneumonias with the Director of Infection Control present. The minutes did not reveal any representation of the respiratory therapy department, or discussion of areas for improvement in that area, or discussion of the fact that for two of three quarters in 2011 the goal of 4.5 average ventilator days per patient was missed.

During the interview of 12/21/11 at 4:00 P.M., the Director of Respiratory Therapy stated he/she was not a member of the committee, and only goes to a meeting if invited. He/she said he/she hasn't been invited for all of 2011.