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Based on facility documentation and staff interviews (EMP) it was determined that the facility failed to ensure that the respiratory services were integrated into the hospital wide QAPI program including focusing on the reduction of medication errors.

Review of facility documentation titled "Department of Pulmonary Medicine, Performance Improvement Goals, Fiscal Year 2017" on February 20, 2018, revealed Goal 1 was to 'achieve = 94% of medication treatments administered as ordered.' The spreadsheet that was part of that same documentation indicated that the facility administered 94 or 95 percent of treatments ordered by the physician during the period of July 2016 through June 2017, except for February 2017 that was noted as 93 percent administered.
Interview with EMP6 on February 20, 2018 at 1:25 PM revealed that she did not know if she 'could show that missed treatments were communicated through the Pharmacy and Therapeutics Committee, the Patient Safety Committee, and further up the chain' to be addressed as a quality improvement issue.
Interview with EMP10 on February 20, 2018, at 1:45 PM revealed if 'percents drop below goal for a three month period, then the issue would go to the Quality Committee and the Board of Trustees.' Further interview with EMP10 revealed that since the average has not fallen below 94%, there has been no communication about this issue with the Quality Committee or Board of Trustees and that there was no need to report this failure because "there was no issue."

Based upon review of facility documentation and staff interviews (EMP), it was determined that the facility failed to ensure that Respiratory Care Services were adequate to meet the needs of the patients as evidenced by the number of missed treatments due to medications and/or clinician unavailability.

Findings include:

Review of facility's tracking spreadsheet titled "Missed Pulmonary Medication FY 2018," on February 20, 2018, indicated the number and percent (rounded) of treatments ordered that were not administered due to 'Clinician Unavailability' as follows:
July 2017: 11 missed treatments (2.1 percent of total missed treatments)
August 2017: 21 missed treatments (4.2 percent of total missed treatments)
September 2017: 19 missed treatments (2.8 percent of total missed treatments)
October 2017: 129 missed treatments (14.1 percent of total missed treatments)
November 2017: 93 missed treatments (11.5 percent of total missed treatments)
December 2017: 140 missed treatments (14.9 percent of total missed treatments)
January 2018: 570 missed treatments (33.9 percent of total missed treatments)


Further review of the same facility tracking spreadsheet on the same day indicated the number and percent (rounded) of treatments ordered that were not administered due to 'Med Not Available' as follows:

July 2017: 20 missed treatments (3.9 percent of total missed treatments)
August 2017: 17 missed treatments (3.4 percent of total missed treatments)
September 2017: 17 missed treatments (2.5 percent of total missed treatments)
October 2017: 33 missed treatments (3.6 percent of total missed treatments)
November 2017: 23 missed treatments (2.8 percent of total missed treatments)
December 2017: 28 missed treatments (3.0 percent of total missed treatments)
January 2018: 45 missed treatments (2.7 percent of total missed treatments)

Review of facility documentation titled "Department of Pulmonary Medicine, Performance Improvement Goals, Fiscal Year 2017" on February 20, 2018, revealed Goal 1 was to 'achieve = 94% of medication treatments administered as ordered.' The spreadsheet that was part of that same documentation indicated that the facility administered 94 or 95 percent of treatments ordered by the physician during the period of July 2016 through June 2017, except for February 2017 that was noted as 93 percent administered.
Interview with EMP10 on February 20, 2018, at 1:45 PM revealed if 'percents drop below goal for a three month period, then the issue would go to the Quality Committee and the Board of Trustees.' Further interview with EMP10 revealed that since the average had not fallen below 94%, there has been no communication about this issue with the Quality Committee or Board of Trustees and that there was no need to report this failure because "there was no issue."

Based on review of facility documentation, medical records (MR) and staff interviews (EMP), it was determined that the facility failed to ensure that there were adequate personnel available to provide for the respiratory care needs of patients.

Findings include:

Review of facility's tracking spreadsheet titled "Missed Pulmonary Medication FY 2018," on February 20, 2018, indicated the number and percent (rounded) of treatments ordered that were missed due to 'Clinician Unavailability' as follows:
July 2017: 11 missed treatments (2.1 percent of total missed treatments)
August 2017: 21 missed treatments (4.2 percent of total missed treatments)
September 2017: 19 missed treatments (2.8 percent of total missed treatments)
October 2017: 129 missed treatments (14.1 percent of total missed treatments)
November 2017: 93 missed treatments (11.5 percent of total missed treatments)
December 2017: 140 missed treatments (14.9 percent of total missed treatments)
January 2018: 570 missed treatments (33.9 percent of total missed treatments)

Review of facility documentation titled "Department of Pulmonary Medicine, Performance Improvement Goals, Fiscal Year 2017" indicated Goal 1 as "Achieve = 94% of medication treatments administered as ordered." Documentation indicated that the facility administered 94 or 95 percent of treatments ordered by the physician during the period of July 2016 through June 2017, except for February 2017 that was noted as 93 percent administered.

For 9 of 20 medical records (MR5, MR11, MR12, MR13, MR15, MR16, MR17, MR18, MR19), documentation revealed respiratory treatments ordered by medical staff were not provided due to 'Clinician Unavailability' or 'Medication not available.'

Review of MR5 on February 6, 2018, revealed that physician's orders for respiratory treatments on February 18, 2018, at 11:52 PM and February 19, 2018, at 4:14 AM were not administered due to 'Clinician Unavailability.'

Review of MR11 on February 20, 2018, revealed that physician's order for respiratory treatment on February 14, 2018, at 4:37 PM was not administered due to 'Clinician Unavailability' and not administered on February 16, 2018, at 8:34 AM due to 'Medication not available.'

Review of MR12 on February 20, 2018, revealed that physician's orders for respiratory treatment on February 14, 2018, at 4:38 PM, February 15, 2018, at 12:01 PM, 9:30 PM, and February 16, 2018, at 4:38 PM were not administered due to 'Clinician Unavailability.'

Review of MR13 on February 20, 2018, revealed that physician's orders for respiratory treatment on January 7, 2018, at 1:07 PM and January 8, 2018, at 12:26 AM were not administered due to 'Clinician Unavailability.'

Review of MR15 on February 20, 2018, revealed that physician's orders for respiratory treatment on December 15, 2017, at 12:33 PM and December 16, 2017, at 1:41 PM were not administered due to 'Clinician Unavailability' and not administered on December 16, 2017, at 9:09 AM due to 'Medication not available.'

Review of MR16 on February 20, 2018, revealed that physician's orders for respiratory treatment on December 15, 2017, at 2:08 PM and December 17, 2017, at 1:44 PM were not administered due to 'Clinician Unavailability.'

Review of MR17 on February 20, 2018, revealed that physician's order for respiratory treatment on November 10, 2017, at 5:55 PM was not administered due to 'Clinician Unavailability.'

Review of MR18 on February 20, 2018, revealed that physician's order for respiratory treatment on November 10, 2017, at 7:57 AM was not administered due to 'Clinician Unavailability.'

Review of MR19 on February 20, 2018, revealed that physician's order for respiratory treatment on December 10, 2017, at 1:13 PM was not administered due to 'Clinician Unavailability.'

Interview with EMP3, on February 6, 2018, at 10:00am confirmed that she is aware that treatments are being missed due to 'Clinician Unavailability.'

Interview with EMP4 and EMP5, on February 6, 2018, at 3:00pm revealed that treatments do get missed due to clinician unavailability.

Interview with EMP11, on February 20, 2018, at 11:15 AM confirmed that the respiratory treatments were not provided due to 'Clinician Unavailability' and 'Medication not available.'

Based on a review of facility documentation, medical records (MR) and staff interviews (EMP), it was determined the facility failed to deliver services in accordance with medical staff directive concerning the reporting of medication errors to attending physicians in 9 of 20 medical records reviewed (MR5, MR11, MR12, MR13, MR15, MR16, MR17, MR18, MR19) and failed to ensure written policies were developed to address the missed treatments of respiratory care services.

Review of facility policy titled "Medication Administration," effective date January 2015, indicated "Errors in administration of medication will be reported immediately to the attending physician, and a notification will be sent as detailed in the Medication Event Policy."

Review of MR5 on February 6, 2018, revealed that physician's orders for respiratory treatments on January 18 at 11:52 PM and January 19 at 4:14 AM were not administered due to 'Clinician Unavailability,' with no notification of the error to the attending physician.

Review of MR11 on February 20, 2018, revealed that physician's order for respiratory treatment on February 14, 2018, at 4:37 PM was not administered due to 'Clinician Unavailability' and not administered on February 16, 2018, at 8:34 AM due to 'Medication not available,' with no notification of the error to the attending physician.

Review of MR12 on February 20, 2018, revealed that physician's orders for respiratory treatment on February 14, 2018, at 4:38 PM, February 15, 2018, at 12:01 PM, 9:30 PM, and February 16, 2018, at 4:38 PM were not administered due to 'Clinician Unavailability,' with no notification of the error to the attending physician.

Review of MR13 on February 20, 2018, revealed that physician's orders for respiratory treatment on January 7, 2018, at 1:07 PM and January 8, 2018, at 12:26 AM were not administered due to 'Clinician Unavailability,' with no notification of the error to the attending physician.

Review of MR15 on February 20, 2018, revealed that physician's orders for respiratory treatment on December 15, 2017, at 12:33 PM and December 16, 2017, at 1:41 PM were not administered due to 'Clinician Unavailability' and not administered on December 16, 2017, at 9:09 AM due to 'Medication not available,' with no notification of the error to the attending physician.

Review of MR16 on February 20, 2018, revealed that physician's orders for respiratory treatment on December 15, 2017, at 2:08 PM and December 17, 2017, at 1:44 PM were not administered due to 'Clinician Unavailability,' with no notification of the error to the attending physician.

Review of MR17 on February 20, 2018, revealed that physician's order for respiratory treatment on November 10, 2017, at 5:55 PM was not administered due to 'Clinician Unavailability,' with no notification of the error to the attending physician.

Review of MR18 on February 20, 2018, revealed that physician's order for respiratory treatment on November 10, 2017, at 7:57 AM was not administered due to 'Clinician Unavailability,' with no notification of the error to the attending physician.

Review of MR19 on February 20, 2018, revealed that physician's order for respiratory treatment on December 10, 2017, at 1:13 PM was not administered due to 'Clinician Unavailability,' with no notification of the error to the attending physician.

Interview with EMP6 on February 20, 2018, at 9:25 AM confirmed that missed treatments are 'medication errors.'

Interview with EMP3, on February 20, 2018, at 1:55 PM, in reference to the Medication Administration policy, revealed "we do not do that (notify physician of missed med) and we have not done it in the past," and that "the physician can look in the MAR to see if a dose was missed." Further interview with EMP3 confirmed that "we do not let physicians know about missed meds.""

Interview with EMP5 on February 6, 2018 at 3:10 PM confirmed respiratory staff prioritize treatments from previous shift therapists so the oncoming therapists know 'who cannot miss a treatment.'

Interview with EMP3 on February 20, 2018 at 10:50 AM revealed that respiratory staff prioritize treatments for patients without a change in the medication order when there is a possibility that all treatments cannot be delivered during a shift. EMP3 further confirmed that there were no specific written policies concerning how missed respiratory treatments are to be addressed and documented.