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Based on review of personnel files, medical records, hospital documents, and interviews, the hospital failed to verify personnel were licensed, trained, and competent.

Findings:

1. In an interview with Staff B on 4/13/12 the surveyor was told Staff B,F, I,J, L had been trained to perform pulmonary functions tests (PFTs). Review of Staff B, F, I, J, and L's personnel file does not include documentation each staff member was trained, evaluated, and found competent with the equipment.
On 4/13/2012 surveyors reviewed Patient record #1, Staff B performed pulmonary function testing. Staff B is a registered nurse. There is no documentation Staff B has the education, training, competency, license/certification, to perform PFTs.

2. On 4/12/12 surveyors reviewed personnel files. 4 of 4 (B,C,D,K) nursing personnel files reviewed did not have evidence of departmental orientation, training, and competencies specific to the duties performed in each department.

3. Three of three (C,D,K) emergency room personnel identified as providing respiratory treatments in the emergency room did not have current competency and evaluation of skills. There was no documentation a respiratory therapist reviewed and evaluated respiratory therapy treatments and tests.

4. On 4/12/12 Staff A told surveyors the facility did not have a respiratory therapist employee or contractor.

Based on record review and interviews with hospital staff, the governing body of the Critical Access Hospital (CAH) does not ensure that bylaws, rules and regulations and policies for the CAH are implemented and monitored to ensure quality health care is provided in a safe environment.

Findings:

1. The facility does not have a full-time or contract respiratory therapist who oversees the respiratory services as required by State and Federal Law. See tag 0154
2. Respiratory and Nursing Policy and Procedures are not reviewed and approved annually. See tag 0271
3. Respiratory Policies indicate only employees of the respiratory department will perform pulmonary function tests on patients. The hospital is not following the respiratory policies and procedures reviewed and approved through the medical staff and governing body. See tag 0271, 0294
4. Nursing personnel providing care in the emergency room do not have documentation indicating they are trained, evaluated, and competent to provide emergency room care. See tag 0271, 0294
5. Nursing personnel providing respiratory care do not have documentation indicating they are trained, evaluated, and competent to provide respiratory treatments and tests. See tag 0294

Based on review of hospital documents, policies and procedures, and interviews with staff the hospital failed to follow respiratory policies and procedures.

Findings:

1. On 4/12/2012 surveyors reviewed the policy and procedure manual for respiratory care. The last update indicated the manual was reviewed/revised in 2010. All policies provided to surveyors included a "scope" which stipulates "Members of Respiratory Therapy Department, as defined by job descriptions. Other policies have a stipulation, "Members of Respiratory Therapy Department, as defined by job descriptions, and nursing staff".

2. According to the respiratory policy "Pulmonary Function Tests" the scope of the policy includes "members of Respiratory Department as described by job description". On 4/12/12 Staff B told surveyors Staff B, F, I, J, L, went through an online education program on a pulmonary function test machine. Staff B showed the machine to the surveyors. Review of all personnel files did not include training documents for the pulmonary function test equipment. Review of Staff B's personnel file did not indicate Staff B was a certified respiratory therapist/registered respiratory therapist. Staff B's job description did not include provisions for providing pulmonary function tests.

3. On 4/12/12 surveyors reviewed two personnel files (Staff I and J). Staff I and J's personnel records indicated a disciplinary notice had been written for failure to provide pulmonary function testing to patients. Staff I and J's personnel records did not include any training materials, competencies, or return demonstration on use of the testing equipment.

4. The above findings were addressed in the exit conference 4/13/2012.

Based on policy and procedure manual review and interview with the hospital staff, the hospital failed to ensure policies are reviewed at least annually.

Findings:

1. On the morning of 4/12/12 surveyors were given copies of the Respiratory Department policy and procedure manual. On 4/12/12 Staff A and Staff B told surveyors the facility was updating all of their policies and not all policies and procedures were current. The Respiratory policy and procedure manual was dated 2010.

2. On the morning of 4/12/12 Nursing policies were provided to surveyors. The latest review and revision was dated 2010.

Based on review of hospital documents and interviews with hospital staff, the hospital does not assure nursing staff are adequately trained to meet the needs of the patients. Four of four nursing personnel did not have departmental orientation, competency, and evaluation for the specialized areas where they worked.

Findings:

1. On the afternoon of 4/12/12 surveyors were provided personnel files. There was no documentation provided indicating Staff (C) had orientation to the hospital and specific departments. There was no documentation Staff C had respiratory treatment training and competencies. Staff C is not a registered nurse or respiratory therapist. There was no job description in the file indicating Staff C's scope of practice. Staff C administered respiratory treatments in the emergency room to patient's #6,7.

2. On the afternoon of 4/12/12 surveyors reviewed four registered nurse personnel files. Four of four registered nurse files did not contain emergency room departmental training. There was no documentation indicating Staff B, D,K, M were trained and competent to provide respiratory therapy treatments and procedures. Staff B performed a pulmonary function test on Patient #1. Staff D, K, M provided respiratory treatments and/or emergency room care for patients #2,3,4,5,6 and 7. The hospital did not provide documentation staff were properly trained and evaluated competent to work in the emergency room and provide respiratory treatments.

3. The above findings were reviewed at the exit conference. No further documentation was provided.