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Based on review of medical records review of credential files, review of restraint policy and procedure, review of Physician Orientation Manual and staff interview, the facility failed to ensure that 2 of 2 physicians (Physicians E and F) who had ordered restraints and whose credential files were reviewed, had received training on the hospital's restraint policy. There were 126 physicians on the Medical Staff List provided by the hospital. This failed practice has the potential to affect all patients requiring the use of restraints.

(A physician credential file contains the information gathered at the time of appointment/reappointment to the hospitals medical staff and includes information such as: an application; list of privileges requested; verifications of education, training, work experience licenses, registrations and references; and background checks)
Findings are:

A. Review of the policy titled Restraint Policy dated 1/2015 revealed the following concerning restraint training:
"A physician or Licensed Independent Practitioner (LIP) primarily responsible for the patient's ongoing care will order the use of a restraint. The physician or LIP will be trained during physician orientation on the restraint policy. Physicians and LIP's who order restraints will receive updates regarding use of restraints at Columbus Community Hospital. Any revisions to the policy will be presented to the Medical Staff thru the Medical Executive Committee and/or General Medical Staff meetings."

B. Review of the medical record for Patient 24 revealed Physicians E and F both ordered restraints for this patient on 11/8/15.

C. Review of the credential files for Physicians E and F revealed no information in the files regarding restraint training and/or physician orientation.

D. Interview with the Director of Quality and Compliance on 12/2/15 at 9:45 AM revealed the following:
-The hospital provided newly appointed physicians their own copy of the Physician Orientation Manual.
-The Physician Orientation Manual included a copy of the Restraint Policy.
-Confirmed the hospital could provide no documentation of restraint training for these physicians.

E. Review of the Physician Orientation Manual revealed a 3-ring binder divided into 23 different sections. One of the sections included the restraint policy.

Based on personnel file review, policy review and staff interview, the Columbus Community Hospital failed to train their staff during orientation on the safe implementation of restraints and seclusion and verification of the staff knowledge and competency with the use of restraints. This has the potential to affect the care of all patients requiring use of restraints during their stay at Columbus Community Hospital. The facility census was 12 Acute Patients, 4 Observation Patients, 1 Outpatient Surgery Patient and 5 Swing Bed Patients on entrance 11/30/15, sample size was 50.

Findings are:

A. A review of 5 of 5 (M, Q, S, T, and V) nursing personnel files hired in the last 6 months, lacked documentation that staff are trained and demonstrated knowledge and competency on the safe use of restraints.

B. A review of the facility policy and procedure titled, "Restraint Policy" dated 1/2015 revealed, "Direct patient care staff members who apply or remove restraints will be trained during nursing orientation before participating in the use of restraints and at annual reviews. They will demonstrate competency in the application of restraints, monitoring, assessment, and providing care for such patient. Training and demonstrated knowledge is based on the specific needs of the patient population. Items included in training are: "...The safe application and use of all types of restraints used in the hospital, including training in how to recognize and respond to signs of physical and psychological distress..."

C. A staff interview on 12/2/15 at 3:30 PM with the Nurse Educator revealed, that when a new RN (Registered Nurse) is hired and in orientation, the Nurse Educator asks them if they are "OK with restraints." The Nurse Educator stated, "I do not pull out restraints with orientation. We do not do seclusion here. I have them read the policy but I do not have anywhere that it is documented their understanding of the policy on the orientation checklists."


D. An interview with the Intensive Care Director and the Nurse Educator on 12/2/15 from 3:30 PM to 4:15 PM, verified that the RN's and Nurse Aides (NA) orientation checklist lacked an area to document the training, demonstration and competency demonstration regarding the use of restraints.

E. An interview with the Intensive Care Director on 12/3/15 at 2:30 PM state, "I would expect the NA's know what a restraint is and what to do with them, such as not to remove them."

Based on personnel file review, policy review and staff interview, the Columbus Community Hospital failed to train their staff during orientation on the safe implementation of restraints and seclusion and verification of the staff knowledge and competency with the use of restraints; monitoring, assessment and the provision of care for a patient in restraints or seclusion. This has the potential to affect the care of all patients requiring use of restraints during their stay at Columbus Community Hospital. The facility census was 12 Acute Patients, 4 Observation Patients, 1 Outpatient Surgery Patient and 5 Swing Bed Patients on entrance 11/30/15, sample size was 50.

Findings are:

A. A review of 5 of 5 (M, Q, S, T, and V) nursing personnel files hired in the last 6 months, lacked documentation that staff are trained and demonstrated knowledge and competency on the safe use of restraints during orientation including monitoring, assessment and care of patients in restraints or seclusion.

B. A review of the facility policy and procedure titled, "Restraint Policy" dated 1/2015 revealed, "Direct patient care staff members who apply or remove restraints will be trained during nursing orientation before participating in the use of restraints and at annual reviews. They will demonstrate competency in the application of restraints, monitoring, assessment, and providing care for such patient. Training and demonstrated knowledge is based on the specific needs of the patient population. Items included in training are: "...The safe application and use of all types of restraints used in the hospital, including training in how to recognize and respond to signs of physical and psychological distress..."

C. A staff interview on 12/2/15 at 3:30 PM with the Nurse Educator revealed, that when a new RN (Registered Nurse) is hired and in orientation, the Nurse Educator asks them if they are "OK with restraints." The Nurse Educator stated, "I do not pull out restraints with orientation. We do not do seclusion here. I have them read the policy but I do not have anywhere that it is documented their understanding of the policy on the orientation checklists."


D. An interview with the Intensive Care Director and the Nurse Educator on 12/2/15 from 3:30 PM to 4:15 PM, verified that the RN's and Nurse Aides (NA) orientation checklist lacked an area to document the training, demonstration and competency demonstration regarding the use of restraints.

E. An interview with the Intensive Care Director on 12/3/15 at 2:30 PM state, "I would expect the NA's know what a restraint is and what to do with them, such as not to remove them." "We do have facility wide restraint training for nursing annually after their orientation."

Based on personnel file review, policy review and staff interview, the Columbus Community Hospital failed to train their staff during orientation on the safe implementation of restraints and seclucion and verification of the staff knowledge and competency related to the techniques to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require the use of restraints or seclusion. This has the potential to affect the care of all patients requiring use of restraints during their stay at Columbus Community Hospital. The facility census was 12 Acute Patients, 4 Observation Patients, 1 Outpatient Surgery Patient and 5 Swing Bed Patients on entrance 11/30/15, sample size was 50.
Findings are:

A. A review of 5 of 5 (M, Q, S, T, and V) nursing personnel files lacked documentation that staff are trained and demonstrated knowledge and competency related to the techniques to identify staff and patient behaviors, events and environmental factors that may trigger circumstances that require the use of restraints or seclusion, including the techniques to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require the use of restraints or seclusion.

B. A review of the facility policy and procedure titled, "Restraint Policy" dated 1/2015 revealed, "Direct patient care staff members who apply or remove restraints will be trained during nursing orientation before participating in the use of restraints and at annual reviews. They will demonstrate competency in the application of restraints, monitoring, assessment, and providing care for such patient. Training and demonstrated knowledge is based on the specific needs of the patient population. Items included in training are: "...Strategies to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require the use of restraints..."

C. An interview with the Intensive Care Director and the Nurse Educator on 12/2/15 from 3:30 PM to 4:15 PM, verified that the RN's and Nurse Aides (NA) orientation checklist lacked an area to document the training, demonstration and competency demonstration regarding the use of restraints. The Nurse Educator stated, "I have them read the policy but I do not have anywhere that it is documented their understanding of the policy on the orientation checklists."

D. An interview with the Intensive Care Director on 12/3/15 at 2:30 PM state, "I would expect the NA's know what a restraint is and what to do with them, such as not to remove them."

Based on personnel file review, policy review and staff interview, the Columbus Community Hospital failed to train their staff during orientation on the safe implementation of restraints and seclusion and verification of the staff knowledge and competency related to the use of nonphysical intervention skills. This has the potential to affect the care of all patients requiring use of restraints during their stay at Columbus Community Hospital. The facility census was 12 Acute Patients, 4 Observation Patients, 1 Outpatient Surgery Patient and 5 Swing Bed Patients on entrance 11/30/15, sample size was 50.
Findings are:

A. A review of 5 of 5 (M, Q, S, T, and V) nursing personnel files lacked documentation that staff are trained and demonstrated knowledge and competency related to the use of nonphysical intervention skills.

B. A review of the facility policy and procedure titled, "Restraint Policy" dated 1/2015 revealed, "Direct patient care staff members who apply or remove restraints will be trained during nursing orientation before participating in the use of restraints and at annual reviews. They will demonstrate competency in the application of restraints, monitoring, assessment, and providing care for such patient. Training and demonstrated knowledge is based on the specific needs of the patient population. Items included in training are: "...The use of nonphysical intervention skills... Alternatives to Restraints..."

C. An interview with the Intensive Care Director and the Nurse Educator on 12/2/15 from 3:30 PM to 4:15 PM, verified that the RN's and Nurse Aides (NA) orientation checklist lacked an area to document the training, demonstration and competency demonstration regarding the use of restraints. The Nurse Educator stated, "I have them read the policy but I do not have anywhere that it is documented their understanding of the policy on the orientation checklists."

D. An interview with the Intensive Care Director on 12/3/15 at 2:30 PM state, "I would expect the NA's know what a restraint is and what to do with them, such as not to remove them."

Based on personnel file review, policy review and staff interview, the Columbus Community Hospital failed to train their staff during orientation on the safe implementation of restraints and seclusion and verification of the staff knowledge and competency related to the use of least restrictive intervention based on the individualized assessment of the patient's medical, or behavioral status or condition. This has the potential to affect the care of all patients requiring use of restraints during their stay at Columbus Community Hospital. The facility census was 12 Acute Patients, 4 Observation Patients, 1 Outpatient Surgery Patient and 5 Swing Bed Patients on entrance 11/30/15, sample size was 50.
Findings are:

A. A review of 5 of 5 (M, Q, S, T, and V) nursing personnel files lacked documentation that staff are trained and demonstrated knowledge and competency related to the use of nonphysical intervention skills.

B. A review of the facility policy and procedure titled, "Restraint Policy" dated 1/2015 revealed, "Direct patient care staff members who apply or remove restraints will be trained during nursing orientation before participating in the use of restraints and at annual reviews. They will demonstrate competency in the application of restraints, monitoring, assessment, and providing care for such patient. Training and demonstrated knowledge is based on the specific needs of the patient population. Items included in training are: "...Methods of choosing the least restrictive intervention based on the individualized assessment of the patient's medical, or behavioral status or condition. ... Least restrictive alternative interventions: efforts must be made to avoid the use of restraints. The alternative chosen will depend on the patient's behavior status..."

C. An interview with the Intensive Care Director and the Nurse Educator on 12/2/15 from 3:30 PM to 4:15 PM, verified that the RN's and Nurse Aides (NA) orientation checklist lacked an area to document the training, demonstration and competency demonstration regarding the use of restraints. The Nurse Educator stated, "I have them read the policy but I do not have anywhere that it is documented their understanding of the policy on the orientation checklists."

D. An interview with the Intensive Care Director on 12/3/15 at 2:30 PM state, "I would expect the NA's know what a restraint is and what to do with them, such as not to remove them."

Based on personnel file review, policy review and staff interview, the Columbus Community Hospital failed to train their staff during orientation on the safe implementation of restraints and seclusion and verification of the staff knowledge, competency related to the use and application of restraints and the ability to recognize and respond to physical and psychological distress. This has the potential to affect the care of all patients requiring use of restraints during their stay at Columbus Community Hospital. The facility census was 12 Acute Patients, 4 Observation Patients, 1 Outpatient Surgery Patient and 5 Swing Bed Patients on entrance 11/30/15, sample size was 50.
Findings are:

A. A review of 5 of 5 (M, Q, S, T, and V) nursing personnel files lacked documentation that staff are trained and demonstrated knowledge and competency related to the use of nonphysical intervention skills.

B. A review of the facility policy and procedure titled, "Restraint Policy" dated 1/2015 revealed, "Direct patient care staff members who apply or remove restraints will be trained during nursing orientation before participating in the use of restraints and at annual reviews. They will demonstrate competency in the application of restraints, monitoring, assessment, and providing care for such patient. Training and demonstrated knowledge is based on the specific needs of the patient population. Items included in training are: The safe application and use of all types of restraints used in the hospital, including training in how to recognize and respond to signs of physical and psychological distress. Monitoring the physical and psychological well-being of the patient who is restrained, including but not limited to, respiratory and circulatory status, skin integrity, vital signs, and any special requirements associated with the one hour in person evaluation..."

C. An interview with the Intensive Care Director and the Nurse Educator on 12/2/15 from 3:30 PM to 4:15 PM, verified that the RN's and Nurse Aides (NA) orientation checklist lacked an area to document the training, demonstration and competency demonstration regarding the use of restraints. The Nurse Educator stated, "I have them read the policy but I do not have anywhere that it is documented their understanding of the policy on the orientation checklists."

D. An interview with the Intensive Care Director on 12/3/15 at 2:30 PM state, "I would expect the NA's know what a restraint is and what to do with them, such as not to remove them."

Based on personnel file review, policy review and staff interview, the Columbus Community Hospital failed to maintain personnel records identifying the training and competency of their staff on the use of restraints. This has the potential to affect the care of all patients requiring use of restraints during their stay at Columbus Community Hospital. The facility census was 12 Acute Patients, 4 Observation Patients, 1 Outpatient Surgery Patient and 5 Swing Bed Patients on entrance 11/30/15, sample size was 50.
Findings are:

A. A review of 5 of 5 (M, Q, S, T, and V) nursing personnel files hired in the last 6 months, lacked documentation that staff are trained and demonstrated knowledge and competency on the safe use of restraints.

B. A review of the facility policy and procedure titled, "Restraint Policy" dated 1/2015 revealed, "Direct patient care staff members who apply or remove restraints will be trained during nursing orientation before participating in the use of restraints and at annual reviews."

C. The Intensive Care Director and the Nurse Educator verified on 12/2/15 during the interview from 3:30 PM to 4:15 PM that the RN's and Nurse Aides (NA) orientation checklist located in the personnel files lacked documention of the training, demonstration and competency demonstration regarding the use of restraints.

Based on observation, review of policies and procedures and staff interview, the facility failed to launder bulk laundry in a manner that protected patients from the potential transmission of communicable diseases in 4 of 4 areas observed that processed bulk laundry (main hospital soiled and clean laundry areas and 3 off-site rehabilitative - physical, occupational and speech therapy areas). The hospital identified no other areas where laundry was processed by hospital staff. This failed practice has the potential to affect all patients of the hospital.

Findings are:

A. Review of the laundry servicesat the hospital on 12/1/15 from 8:10 AM to 9:50 AM with the Lead Linen Processor, Laundry Aide - W and the Infection Control Coordinator revealed Laundry Aide - W was transferring bags of soiled linen from a smaller transport cart to a larger storage cart wearing gloves and no protective covering over clothing. Interview with the Lead Linen Processor and Laundry Aide - W during this observation revealed laundry staff remove their gloves and wash hand prior to going to the clean laundry room but wear the same clothes into that area.

B. Review of the Laundry services on 12/1/15 from 8:10 AM to 9:50 AM also revealed the soiled laundry area contained 2 household style washing machines and the clean laundry area had 2 household style washing machines. Interview with the Lead Linen Processor and Laundry Aide - W revealed the following:
-Items that were laundered in the machines included, sleep lab sheets and towels, table clothes from the kitchen, items from the obstetrics area such as baby buntings, obstetric belts (used to monitor fetal heart rates during delivery of babies), privacy curtains from patient rooms and rags from housekeeping.
-The laundry detergent used in the washing machines was a household detergent with no bleach.
-Did not know the temperature of the water going to the washing machine.

Interview with the Facilities Management Director during the review of laundry on 12/1/15 from 8:10 AM to 9:50 AM revealed the washing machines were hooked to the domestic water supply for the hospital and the water would be no more than 120 degrees Fahrenheit.

C. A request for policies and procedures on processing of laundry by hospital personnel resulting in one policy being provided. This policy was titled Daily Pickup of Laundry and Transportation to Linen Service dated 3/9/12. Interview with Director of Accreditation and Environmental safety on 12/1/15 at 1:04 PM confirmed that this policy was the only policy for laundry services.








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D. Observation of the free standing off site rehabilitation outpatient service identified as Wiggles and Giggles on 12/2/15 from 2:00 PM - 2:15 PM revealed patient linens are washed and dried in the department. Observation found 1 room with a household washer and dryer side by side without separation. Laundry detergent found in the cupboard above the washer was "All Free detergent" a common household detergent used in residential settings.
Interview with the Manager of Wiggles and Giggles on 12/2/15 at 2:15 PM revealed staff use the washer and dryer to wash towels which have been used to wipe patient faces and sheets which were used to cover the mats used during therapy. The manager stated the site provides Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST) to children from infancy to adolescence
Hot water maximum temperature tested by maintenance on 12/2/15 was reported to be 110 degrees Fahrenheit at 2:40 PM.

E. Observation on 12/2/15 from 2:35 PM to 2:45 PM revealed the same building which has Wiggles and Giggles also houses a separate rehabilitative adult outpatient program identified as Rehabilitative Services. The program has it's own household washer and dryer side by side in a room without separation. The cupboard above the washer contained Tide and All a common household detergents. Bleach was also present.
Interview with the Director of Rehabilitation Services on 12/2/15 at 2:35 PM revealed the staff use the washer and dryer to do the linens, towels, wash cloths, pillow cases and patient gowns. The Director reported the staff do 9 loads of patient soiled linens per day. Bleach is used in some loads but not all per the Director.
The maximum water temperature tested and reported by maintenance was 111.7 degrees Fahrenheit on 12/2/15 at 2:45 PM.

F. Observation of a separately located off campus outpatient rehabilitation program identified as Premier PT was done on 12/2/15 from 3:10 PM until 3:40 PM. The facility has a household washer and dryer side in a room without separation. Above the washer Tide Free and Gentle and Bleach were found.
Interview with the Director of Premier PT on 12/2/15 at 3:10 PM revealed the facility only provides PT services. The Director stated the staff do not use bleach with every load. They wash towels, pillow cases, sheets, hot pack covers and Alter G Shorts. Alter G shorts are a special short worn by patients which enables them to be zipped into an adjustable weight bearing therapy device. The Director stated maintenance checked their maximum water temperature at 7:30 AM on 12/2/15 and reported the temperature was 115 degrees Fahrenheit.

G. Interview with the the Director for Accreditation and Environmental Safety Coordinator on 12/7/15 at 1:25 PM confirmed the facility has no laundry policies/procedures for doing laundry in the outpatient areas.

H. Interview with the Infection Control Coordinator on 12/1/15 at 10:30 AM revealed "I thought all patient care related items were laundered offsite. The process changed at some point not sure when."

Review of the Center for Disease Control publication Guidelines for Environmental Infection Control in Health-Care Facilities dated 2003 revealed the following for doing laundry in healthcare facilities:
-"A laundry facility is usually partitioned into two separate areas - a 'dirty' area for receiving and handling the soiled laundry and a 'clean' area for processing the washed items."
-"Laundry workers should wear appropriate personal protective equipment (e.g., gloves and protective garments) while sorting soiled fabrics and textiles."
-"The antimicrobial action of the laundering process results from a combination of mechanical, thermal and chemical factors....Hot water provides an effective means of destroying microorganisms. A temperature of at least 160 degree Fahrenheit for a minimum of 25 minutes is commonly recommended for hot-water washing...The use of chlorine bleach assures an extra margin of safety."

Based on observations, policy and procedure review and staff interviews; the hospital failed to provide surgical services in accordance with acceptable standards of practice by failing to ensure 36 vials of Dantrolene Sodium were available in the immediate OB (obstetrics) surgery suite to meet the potential emergent need of a patient in a Malignant Hyperthermia crisis. The average number of OB surgeries performed at the hospital on a monthly basis is 15.


These findings presented a serious threat to the health and safety of all surgery patients susceptible to Malignant Hyperthermia (MH). The Malignant Hyperthermia Association of the United States (MHAUS) stated "High incidence areas in the United States include Wisconsin, Nebraska, West Virginia and Michigan. However, the prevalence of genetic change that predisposes to MH is much higher. About 1 in 2,00 patients harbor a genetic change that makes them susceptible to MH." Review of the surgery schedule dated 11/30/15 revealed a a patient scheduled for a cesarean section and bilateral tubal ligation (permanent method of birth control). The hospital had one MH kit that was located in the main OR (operating room) on first floor that would have to be taken to the OB surgery suite located on second floor if needed for a MH crisis, leaving the 3 active ORs without an MH kit. Interview with the Director of Surgical Service on 12/1/15 at 12:00 noon stated they have done surgery on 301 lb (pound) patient in the past year and a 420 lb person in the past 3 years. The average number of surgical procedures performed at the hospital on a monthly basis is 220.

The Condition of Participation for Surgical Services is out of compliance due to the seriousness of the deficiency cited at A-0951.

Based on observations, review of policy and procedure, review of Risk Assessment Scoring Tool and staff interview; the hospital failed to provide surgical services in accordance with acceptable standards of care by failing to ensure 36 vials of Dantrolene Sodium were available in the immediate OB (obstetrics) area to meet the emergent need of a patient in a Malignant Hyperthermia (MH) crisis. This failed practice had the potential to affect all surgical patients using inhaled general anesthetics and Succinycholine Chloride (A short-acting depolarizing skeletal muscle relaxant). The average number of OB surgeries performed at the hospital on a monthly bases is 15 with the average of 2 cases being done under general anesthesia. The average number of surgical procedures performed at the hospital on a monthly basis is 220 with the average of 140 cases being done under general anesthesia.

Findings are:


A. Interview with the Nurse Manager of Maternal Child on 12/1/15 at 9:40 AM while touring the OB surgery suite revealed that the "MH cart is located in OR" (operating room).

-Interview with the Director of Surgical Service on 12/1/15 at 9:40 AM confirmed the MH cart was in OR and that they could have the MH cart up from the OR to the OB suite "in less than 1 minute, it has been timed several times". The OR has 3 active operating rooms. The Director of Surgical Service stated that it was decided to order a second set of 36 vials of Dantrolene to be stored in the c-section room as a "best practice standard to have the second set." The Director of Surgical Service stated the second cart had no exact date but the Dantrolene was ordered yesterday.

-Interview on 12/1/15 at 10:09 AM with Certified Pharmacy Technician A stated that if the Dantrolene was being delivered by Fedex it should be in the pharmacy at 2:30 PM today (12/1/15).

B. Observation on 12/1/15 at 10:16 AM confirmed 36 vials of Dantrolene Sodium with the expiration date of 6/2017 is in the MH kit in the OR.

C. Observation on 12/1/15 at 12:02 of a mock (not real) MH drill revealed House Supervisor A took the elevator and arrived with the MH kit from the OR at 12:05.

D. Review of the Risk Assessment Scoring Tool (dated 11/25/15) stated "Dantrolene Sodium is currently only stored in the OR. CMS recommendation per memo from State of NE DHHS (Nebraska Department of Health and Human Services) leadership is to have Dantrolene Sodium stored in all operating room locations." The Dantrolene was ordered by the Pharmacy Director on 11/30/15 to be "available in house 12/1/15 @ (at) 1130 AM".

E. Review of policy and procedure titled Malignant Hyperthermia Protocol stated "Obtain MH cart (kept in Central Core Room)."

Based on staff interview and a review of the policy titled "Respiratory Care Shared Governance Guidelines," the Columbus Community Hospital failed to provide a physician director of respiratory care services to provide services for the facility. This failure had the potential to affect the quality of respiratory care provided to all patients of the Columbus Community Hospital who required or received respiratory care services. The facility census was 12 Acute Patients, 4 Observation Patients, 1 Outpatient Surgery Patient and 5 Swing Bed Patients on entrance 11/30/15, Sample size was 50.
Findings are:
A. An interview with the Director of Respiratory Therapy on 11/30/15 at 3:00 PM revealed, the hospital doesn't really have a Physician Director of Respiratory Services. The hospital had teams with multiple doctors. The team that Respiratory Services is part of was Team 1, which included; Emergency Room Physicians, Hospitalists, Primary Care Physicians, Cardiologist, Pediatricians and Surgeons. Team 1 meets quarterly. "If I had to pick one that I would say was the director I guess I would say Doctor (name) F (a Hospitalist), as that doctor is the chairman of the team."
B. Review of the "Respiratory Care Shared Governance Guidelines" policy dated 8/2015, revealed, "Shared Governance is based on the belief that healthcare professionals working closely with patients are in the best position to make decisions related to clinical practice..."
C. An interview with the Vice President of Nursing (VP-Nrsg) on 12/2/15 at 5:05 PM during the evening status meeting with the staff, verified that there is not a specific physician identified as the Director of Respiratory Services. The VP-Nrsg revealed that the Sleep lab does have a Pulmonologist as the Director and that the VP-Nrsg will visit with the Pulmonologist to see if there would be an interest to expand to also being the Director of Respiratory Services. The Respiratory Services is currently under the direction of the Team 1 group of physicians.