HospitalInspections.org

Based on record review and interview, the facility failed to ensure hospital staff employment records contained training and education requirements that were maintained and stored for review. The facility also failed to ensure an established process of record retention compliance in 5 (#55, #57, #58, #59, and #60) out of 7 (#18, #47, #55, #57, #58, #59 and #60) employee charts reviewed.

An interview was conducted with Staff #18 on 9/15/21 Staff #18 stated that the facility started using Nitric Oxide with ventilated patients. Staff #18 stated that she and other RT's had gone through a training with a pharmaceutical company for administration of Nitric Oxide on 7/1/19. Staff #18 stated that she continues with training for her staff using a model and hands on check off. Staff #18 stated that she did not keep any of the training records for employees that were RAC or Agency. Staff #18 stated "I thought when they left you could throw the files away." Staff #18 confirmed that she did not give any training to HR and it would not be in the HR files for the full time or part time employees. Staff #18 brought the surveyor employee files from her office, but they were mixed up and very disorganized. Review of Patient #4's chart revealed he received Nitric Oxide from Staff #18, #47, #55, #57, #58, #59 and #60. There were no found competencies to administer this treatment for Staff #55, #57, #58, #59, and #60.

An interview with Staff # 27 and #1 was conducted on 9/16/21. Staff #27 revealed she was the interim Human Resource (HR) director and started at this facility 6 days ago. Staff #27 confirmed the HR files were in "bad shape." Staff #27 stated that she just started to address the problem and was unable to retrieve information unless they were in the HR files. Staff #27 was not aware that RAC and Agency RT employee files were being discarded when they terminated. Staff #27 was not aware of employee training kept in other files and not sent to the original HR file. Staff # 1 stated that he was aware the HR department was not in good shape and he terminated the HR director. Staff #1 was not aware that contracted staff employee files were being discarded after termination.

Based on record review, documentation, and interview the Governing Body failed to


A. ensure that an emergent or Disaster Surge Staffing plan for all clinical staff was developed, and approved by the Medical Staff and Governing Board, to ensure patient safety.

B. monitor and supervise Respiratory Therapist (RT) to ensure therapist were not placing patients on Bipap and determining settings without a physician order in 5 of 5 (#1, #2, #6, #11, and #12) patient records reviewed.

C. ensure policy, procedures, and training for Vapotherm and Airvo were completed. Ensure physicians orders were in place for critical patients on Vapotherm, Airvo, Bipap or Bipap settings for 5 out of 5(#1, #6, #7, #9, #13) patient charts reviewed.

D. ensure that a policy and/or procedure was developed and approved by the Medical Staff for the adult Nitric (inhaled Nitric Oxide used in the treatment of critically ill COVID-19 patients) inhalation treatments and Epoprostenol Sodium (Flolan-an inhaled pulmonary vasodilator used to assist with breathing in critically ill COVID-19 patients) inhalation treatments. The facility also failed to ensure that education, training, and competencies for RT's was completed before the initiation, assessment, and monitoring of patients receiving Nitric and Flolan inhalation treatments.

E. ensure that documentation was completed on Patient #13's medical record when Bipap was removed before patient went into respiratory failure and failure to investigate Patient #13's death.

F. ensure that patients were placed in a safe location to hear vital alarms to ensure patients were receiving oxygen as ordered.


G. ensure that Physical Therapy (PT) staff completed education, training, and competencies for titrating the oxygen flow rate prior to patients therapy. PT staff was titrating the oxygen flow rate without a physician order or approved facility policy or protocol in 3 (Pts #6, #7, and # 9) of 3 patient medical records reviewed.





Cross Refer to Tag A0144


H. ensure the Quality Department was identifying issues and developing effective performance improvements concerning patient care, safety, staffing shortages, changes in treatments, supply issues and reporting from all departments to promote safety and quality of care.

Cross Refer to Tag A0283

Based upon observation, record review, and interview, the facility failed to


A. ensure that an emergent or Disaster Surge Staffing plan for all clinical staff was developed, and approved by the Medical Staff and Governing Board, to ensure patient safety.

B. monitor and supervise Respiratory Therapist (RT) to ensure therapist were not placing patients on Bipap and determining settings without a physician order in 5 of 5 (#1, #2, #6, #11, and #12) patient records reviewed.

C. ensure policy, procedures, and training for Vapotherm and Airvo were completed. Ensure physicians orders were in place for critical patients on Vapotherm, Airvo, Bipap or Bipap settings for 5 out of 5(#1, #6, #7, #9, #13) patient charts reviewed.

D. ensure that a policy and/or procedure was developed and approved by the Medical Staff for the adult Nitric (inhaled Nitric Oxide used in the treatment of critically ill COVID-19 patients) inhalation treatments and Epoprostenol Sodium (Flolan-an inhaled pulmonary vasodilator used to assist with breathing in critically ill COVID-19 patients) inhalation treatments. The facility also failed to ensure that education, training, and competencies for RT's was completed before the initiation, assessment, and monitoring of patients receiving Nitric and Flolan inhalation treatments.

E. document that Patient #13's Bipap was removed before patient went into respiratory failure and failure to investigate Patient #13's death.

F. place patients in a safe location to hear vital alarms to ensure patients were receiving oxygen as ordered.


G. ensure that Physical Therapy (PT) staff completed education, training, and competencies for titrating the oxygen flow rate prior to patients therapy. PT Staff was titrating the oxygen flow rate without a physician order or approved facility policy or protocol in 3 (Pts #6, #7, and # 9) of 3 patient medical records reviewed.

It was determined that these deficient practices posed an Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, impairment, and /or subsequent death.

Cross Refer to Tag A0144

Based on observation, document review, and interview the facility failed to:

A. monitor and supervise Respiratory Therapist (RT) to ensure therapist were not placing patients on Bipap and determining settings without a physician order in 5 of 5 (#1, #2, #6, #11, and #12) patient records reviewed.

B. document that Patient #13's Bipap was removed before patient went into respiratory failure and failure to investigate Patient #13's death.

C. place patients in a safe location to hear vital alarms to ensure patients were receiving oxygen as ordered.

D. ensure that Physical Therapy (PT) staff completed education, training, and competencies for titrating the oxygen flow rate prior to patients therapy. PT staff was titrating the oxygen flow rate without a physician order or approved facility policy or protocol in 3 (Pts #6, #7, and # 9) of 3 patient medical records reviewed.

E. ensure that an emergent or Disaster Surge Staffing plan for all clinical staff was developed, and approved by the Medical Staff and Governing Board, to ensure patient safety.

F. Ensure physicians orders were in place for critical patients on Vapotherm, Airvo, Bipap or Bipap settings for 5 out of 5(#1, #6, #7, #9, #13) patient charts reviewed. ensure policy, procedures, and training for Vapotherm and Airvo were completed.

G. ensure that a policy and/or procedure was developed and approved by the Medical Staff for the adult NITRIC (inhaled Nitric Oxide used in the treatment of critically ill COVID-19 patients) inhalation treatments and Epoprostenol Sodium (FLOLAN-an inhaled pulmonary vasodilator used to assist with breathing in critically ill COVID-19 patients) inhalation treatments. The facility also failed to ensure that education, training, and competencies for RT's was completed before the initiation, assessment, and monitoring of patients receiving Nitric and Flolan inhalation treatments.

These deficient practices were identified and determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.





A. Patient #1 was a 58-year-old male that presented to the ER via EMS with complaints of SOB.
An order was written on 9/3/2021 at 3:48 AM by Staff #52 (MD) to "Admit to Inpatient."

A review of the Physicians order was as follows:

" ...9/07/2021 at 4:05 AM by Staff #46 (MD), BIPAP/CPAP/AVAP ..."

Staff #8 confirmed there was no settings ordered for the BIPAP.


A review of the documents titled, "RT-Ventilator Flowsheet" was as follows:

" ...9/07/2021 by Staff # 26 (RT) at 04:49

Ventilator Type V-60
Ventilator Mode BIPAP
Respirations Set 16
VT- Expired (ml) 607
Peep-CPAP-EPAP 10


9/07/2021 by Staff #29 (RT) at 08:40

Ventilator Mode BIPAP
Respirations Set 16
VT- Expired (ml) 582
FIO2 90
VE 23.7
IPAP 14
EPAP 6


9/07/2021 by Staff #26 (RT) and #29 (RT) at 15:00 (3:00 PM)

Ventilator Mode BIPAP
Respirations Set 16
VT- Expired (ml) 812
FIO2 90
VE 22.1
IPAP 14
EPAP 6 ..."

Staff #6 (RN) and Staff #8 (RN) confirmed Patient #1 was on BIPAP therapy for greater than 10 hours without settings from a physician.


Patient #2

Patient #2 was a 79-year-old female admitted to the ER on 9/09/2021 at 15:38 (3:38 PM). Patient #2 was brought to the facility via EMS from the dialysis center with complaints of general weakness and shortness of breath. Upon arrival Patient #2 was on 3L (liters) of oxygen with a 90% oxygen saturation.

Vital signs were as follows:

" ...9/09
15:50 (3:50 PM) Pulse 108 Respirations 35 Pulse Ox 76% on 15% Non-rebreather mask
15:58 (3:58 PM) Pulse Ox 96% on 100% BiPap
16:06 (4:06 PM) Pulse 99 Respirations 20 Pulse Ox 99% on 100% Bipap
19:00 (7:00 PM) Pulse 72 Respirations 20 Temp 98.0 Pulse Ox 97% on BiPap
20:00 (8:00 PM) Pulse 77 Respirations 24 Temp 98.0 Pulse Ox 94% on Non-rebreather mask

9/10
00:42 (12:42 AM) Pulse 86 Respirations 20 Temp 98.0 Pulse Ox 94% on BiPap ..."


A review of the Physicians orders written by Staff #45 (MD) was as follows:

" ...9/09 15:53 (3:53 PM) Call RT
9/09 15:53 (3:53 PM) 02 @ 2 lpm via NC
9/09 15:53 (3:53 PM) Respiratory Therapy Order
9/10 00:19 (12:19 AM) BIPAP/CPAP ..."

Staff #6 (RN) confirmed no settings for the Bipap were documented on the order by Staff #45 (MD).



A review of the document titled, "RT- Ventilator Flowsheet" dated 9/09/2021 at 22:38 (10:38 PM) by Staff #47 (RT) was as follows:

" ...Respiratory Treatment(s) Administered
Bipap INI (initial)
Ventilator Mode-AVAPS
VT-Set (ml) 485
Respirations Set 20
VT Expired (ml) 431
PEEP 10 ..."

During a review of Patient #2's medical record, Staff #8 (RN) confirmed no BiPAP settings were ordered by Staff #45 (MD) on 9/10/2021 at 00:19 (12:19 AM) before applying the BIPAP to Patient #2.

Further review of Patient #2's medical record revealed the following:

" ...On 9/10/2021 at 4:25 (unable to determine if this was AM or PM) Staff #36 (RT) entered an order for Staff #14 (MD). The order was as follows:

"BIPAP/CPAP Routine Once" No settings were ordered by Staff #14 (MD).


A review of the document titled, "RT- Ventilator Flowsheet" dated 9/10/2021 at 02:07AM by Staff #36 (RT) was as follows:

" ...Respiratory Treatment(s) Administered
Bipap Subsequent
Ventilator Mode-AVAPS
VT-Set (ml) 485
Respirations Set 20
VT Expired (ml) 329
PEEP 10
Sensitivity 2LPM
Pressure Limit 30 ..."


Patient #2 remained on the BiPAP with the above settings from 9/09/2021 until 9/11/2021 at 20:00 (8:00 PM) when Staff #48 (RN) documented that Patient #2 was on a nasal cannula. No Physician Order was in the medical record to discontinue the BiPAP.



A review of the document titled, "Assessment-General Nursing" on 9/11/2021 by Staff #48 (RN) was as follows:

" ...RESPIRATORY SYSTEM
Oxygen Delivery Device
Nasal Cannula
Flow Rate
15
Flow Method
Liters Per Minute ..."



Further review of the medical record revealed Patient #2 was placed back on the BIPAP on 9/12/2021 at 1:34 AM without Physician orders for the BIPAP settings.

A review of the document titled, "RT- Ventilator Flowsheet" dated 09/12/2021 at 01:34 AM by Staff #36 (RT) was as follows:

" ...Respiratory Treatment(s) Administered
Bipap Subsequent
Ventilator Mode-AVAPS
VT-Set (ml) 485
Respirations Set 20
VT Expired (ml) 869
PEEP 10
Sensitivity 2LPM ..."


On 9/12/2021 at 9:15 AM Staff #49 (RT) entered an order for Staff #14. The order was as follows:
" ...BIPAP/CPAP Routine Once ..." No setting was ordered for the BIPAP by Staff #14 (MD).



A review of the document titled, "RT- Ventilator Flowsheet" dated 09/12/2021 at 20:19 (8:19 PM) and 9/13/2021 at 7:51 AM by Staff #50 (RT) was as follows:

" ...Current Breathing Pattern
Regular
HFNC (High Flow Nasal Cannula)
O2L:15 ..."


No Physician Order was in the medical record to discontinue the BiPAP and place Patient #2 on a HFNC.

A complete BIPAP order was written by Staff #51 (NP) with settings on 9/13/2021 at 10:55 AM. This was 4 days after the BIPAP was initiated on Patient #2.
.
Patient #2 was placed on BIPAP and removed from BIPAP without a complete physician order from 9/09-9/13/2021. RT was determining the BIPAP settings and subsequently, Patient #2 was placed on a ventilator on 9/14/2021.

Patient #11 was ordered Bipap in the Emergency Department (ED) on 08/30
22:29 The physician order stated, "BiPAP: Place pt. on BiPAP." Review of the nurse's notes revealed the RT Staff #36 stated, "08/30 22:35 Inspiratory pressure is 12 Expiratory pressure is 6 Respiratory rate is 16 O2 percentage is 100 Alarms set Alarms audible Low pressure alarm is on". There was no order written for settings.

Review of Patient #12's ED physician orders stated, "BiPAP: Place pt. on BiPAP" on 01/15/21 at 15:16. The RT that signed the Nurses note Staff #38 documented, "16:15 01/15 16:37 Inspiratory pressure is 500 Expiratory pressure is 10 Respiratory rate is 16 O2 percentage is 70. Initial Med Neb Given as ordered. Respiratory Assessment: Breath sounds are diminished bilaterally." There was no order written for settings.

Review of Patient #6's chart revealed on 9/14/21 11:39 Staff # 28 documented, "O2 SAT 77 CO PLACED ON BIPAP SAT SLOWLY IMPROVED."

Review of Patient #6's chart revealed on 9/14/21 at 11:41 Staff #28 documented, " Pt found hypoxic this morning during first round: her O2 Sat dropped to 34% while she was on 90% airvo and immediately placed on BiPAP and Sat recovered slowly to 89%. Pt seems not tolerating off BiPAP overnight which cause desaturation event might be due to weakness. This is the second night pt decompensating on airvo at night. physician notified the incident."

Review of Patient #6's physician orders dated 9/14/21 at 16:08 stated, "Desc: BIPAP/CPAP/AVAP ORDER-SETTINGS Start: 9/14/21 16:07 Priority: Routine Frequency: ONCE Occurrences: 1 Comments: bipap current settings q hs Ancillary Instructions: SETTINGS ARE REQUIRED." There were no settings ordered.



According to The National Institue of Health (NIH) "A Bilevel Positive Airway Pressure (BiPAP) is a positive airway pressure device used to assist a critical patient with breathing that requires specific settings to ensure the safety of all patients. These specific settings include; Inspiratory positive airway pressure (IPAP), Expiratory positive airway pressure (EPAP), FiO2 (the fraction of inspired O2 in %), and Respiratory Rate are the most common settings used.) before starting treatment on patients.

Inspiratory Positive Airway Pressure (IPAP) settings can be varied to achieve adequate tidal volumes, by allowing patients to breath to a pre-set inspiratory pressure. To achieve adequate tidal volumes, the IPAP can range from 12 to 35cmH2O. Expiratory Positive Airway Pressure (EPAP) works on the same principles as PEEP in CPAP devices, preventing alveolar collapse on expiration which is maintained above atmospheric pressure. To overcome the difficulty of breathing on a ventilator (including valves) and increase of dead space from the ventilator tubing is achieved by pressure support. Pressure support is calculated by minus IPAP from EPAP, and it is recommended that there should be a difference of at least 8cmH2O,5 with supplementary oxygen provided, if needed, to achieve oxygenation. Some BiPAP ventilators offer a ' ramp ' setting, also termed ' rise time ' , which allows the pressure to be slowly increased over the first few minutes of ventilation until the required pressure is reached. This prevents barotrauma and is considered less distressing for the patient when treatment is commenced. Using this approach, a 25% rise time will take up 25% of the total inspiratory time before the peak pressure is reached."

Each patient is different, and settings should be applied as ordered by the physician. The facility should take in consideration or have specific guidelines for the Bipap application such as the patients age, pertinent past and current medical history, individual need, and ability to keep the mask on.

Respiratory Therapists (RT's) were determining settings without physician orders or guidelines.


In the afternoon on 9/14/2021 Staff #24 confirmed patients were frequently placed on BIPAPs and removed from BIPAPs without a complete physician order. She also confirmed that the BIPAP settings were often determined by the RT.


Staff #3 confirmed the facility did not have a policy on the use of BIPAP Therapy.


An interview was conducted on the afternoon of 9/14/2021 with Staff #23 (MD). Staff #23 (MD) was asked if he was aware that patients were being put on a BIPAP without BIPAP settings being ordered by the physician. Staff #23 (MD) stated, "Due to the pandemic, there is lack of specific orders. I think there is good patient care I just do not think it is documented." Staff #23 (MD) was then made aware that some patients were going 3 days or more without the BIPAP settings being ordered from a physician. Staff #23 (MD) stated, "Well I can understand that sometimes the physicians do not get the orders put in for several days, but I think more than 3 days is too long."

Staff #2, #3, #4, #6 and #8 confirmed the findings.


An interview was conducted on 9/14/2021 with Staff #2, #4, and #6. This surveyor informed the Staff that in 2019 the facility was cited with an Immediate Jeopardy for not having ventilator settings ordered from the physicians when a patient was placed on the ventilator. Staff #6 stated, "Yes, we remember and at that time we determined that it was a computer problem. In the physician orders for ventilator settings there is a space for settings to be entered. There is not a hard stop for them to be reminded to complete that part of the order. That is one of the items we monitor through QAPI. I have talked to Corporate about this several times. The problem is that we cannot set a hard stop for the physicians to complete that area. The computer would place a hard stop on every physician order entered. It was then determined that we would not be implementing a process for this. We entered information into a space on the ventilator orders that reads, "Settings are required" to remind the physicians that this information has to be entered. This information is also on the BIPAP orders, but we do not monitor those orders through QAPI like we do the vent orders."



B. During a complaint visit to the facility on 9-13-21 an anonymous complaint was made to the surveyor concerning patients becoming confused and removing Bipaps. The complainant stated the patients were on the first floor and were on Bipap behind closed doors. The patient's alarms would go off and the nursing staff could not hear the alarms and patients would become decompensated and die. The complainant stated there were several instances but could not remember patient names. The complainant stated that administration was aware and decided to leave the doors open to the patient rooms even though the floors were not designed as negative pressure areas. Staff and visitors were always exposed to COVID patients.

Due to COVID being spread by respiratory droplets, patients that are using any kind of O2 device such as Ventilators, Bipaps, Vasotherms, or Airvos should be in an area to prevent secretions from traveling to non-infected areas. One way to do this is with a negative pressure room, in which a lower air pressure allows outside air into the room; any air that flows out of the room had to pass through a filter. Staff #6 confirmed that the second floor and rooms were not negative pressured rooms.

During an interview with Staff #18 on the morning of 9/18/21. Staff #18 stated that she was aware of a patient on the 1st floor that removed his bipap and was found deceased. Staff #18 stated that she was unaware of the patient's name or date. Staff #18 stated that there was a problem of not hearing the alarms going off on the Bipaps and administration had decided to leave the doors open to the Covid patient rooms. This way the staff could hear the alarms.

An interview with Staff #5 and #6 was conducted on 9/16/21. Staff #5 and #6 were asked if they were aware of any deaths due to Bipaps taken off by the patients resulting in death. Staff #5 denied any knowledge and Staff #6 stated that she was not aware. Staff #6 came back to the surveyor later and stated there was no occurrence reports or an RCA done by her predecessor. Staff #6 and Staff #5 came back to the surveyor and stated they believe they may have the patient's chart but was not sure if Patient #13 was the patient.

Review of Patient #13's chart revealed he was a 66-year-old male. Patient #13 came to the Emergency Department (ED) on 12/24/2020 Time: 13:53 (1:53PM) with a cough and fever.

The patient was diagnosed with COVID/ pneumonia. Review of the ED physician Notes dated 12/24/20 at 16:35 stated, "ED course: Patient is positive for COVID. Chest x-rays also concerning for pneumonia. Patient reports he is feeling better after being in the ER. O2 stats in the 90s. Patient is adamant that he does not want to be in the hospital for Christmas and wants to go home. Reports that he will return to the ER if symptoms worsen or new symptoms arise. Form filled out for Bamlanivimab (is a monoclonal antibody for COVID) with help of social worker_____. Importance of follow-up stressed. Warning signs return instructions warning instructions discussed in detail. Discharge with meds, follow-up return instructions. Also advised to start taking vitamin D and zinc at home." Patient #13 was discharged.

Review of Patient #13's chart revealed he returned to the ER by ambulance on 12/26/20. Review of the ED physician notes stated on 12/26/20 at 0657 (6:57AM), "This 66 yrs old White Male presents to ED via EMS - Ground with complaints of Breathing Difficulty.

12/26 0657 Onset: The symptoms/episode began/occurred this morning. Associated signs and symptoms: Pertinent positives: fever. 66 y old m Covid positive (diagnosed at 12/24/20) coming to the ER today with complaints of shortness of breath. Symptoms worse this morning. As per EMS pt's 02 sats were in the 60s on CPAP. Pt was also diagnosed with pneumonia and is taking Levaquin. Was given 0.5 of EPI by EMS. Denies chest pain, nausea, vomiting or other complaints."

Review of the Nurses Notes revealed "12/26/20 06:49 Presenting complaint: EMS states: was called by for difficulty breathing. Wife woke up to him breathing hard. Was diagnosed with COVID here on 12/24. Oxygen sat was 65% on his home CPAP. Put him on 15L on EMS CPAP which brought him up to 95%. Had a 101.3 temp for EMS. Gave him 0.5 of Epi IM. Dstick was 405." (CPAP- Continuous positive airway pressure (CPAP) therapy is a common treatment for obstructive sleep apnea. A CPAP machine uses a hose and mask or nosepiece to deliver constant and steady air pressure.)

Review of the ED physician notes stated Patient #13 was on a BIPAP at 6:57AM on the vital sign section. The physician then documented Patient #13 was on a CPAP at 8:05AM. There was no clear confirmation in the chart if Patient #13 was on a CPAP or BIPAP. Bipap's are different from a CPAP. BiPAP refers to Bilevel or two-level Positive Airway Pressure. Like CPAP, this treatment works by sending air through a tube into a mask that fits over the nose. While CPAP generally delivers a single pressure, BiPAP delivers two: an inhale pressure and an exhale pressure. The Bipap requires settings to make sure the airway pressure is correct for the patient.

Review of the physician orders revealed on 12/26/20 at 09:34AM to admit to inpatient status. Another order read "respiratory therapy order". There were no written directions for what the respiratory orders were for.

Review of the ED Nurses documentation sheet dated 12/26/20 at 06:59AM the Respiratory Therapist (RT) documented, "Inspiratory pressure is 14 Expiratory pressure is 8 Respiratory rate is 14 02 percentage is 100. Initial MDI (metered dose inhaler) given. Patient tolerated procedure well without adverse effect Number of puffs given." There were no physician orders found for Bipap or Bipap settings.

An interview was conducted on 9/14/21 with Respiratory Therapist (RT) Staff #12, 24, and 25. Staff #25 stated that when RT gets orders for Bipap they sometimes get verbal orders but most of the time they just adjust the settings with no physician order. Staff #12 and 25 confirmed that they have set Bipap without physician orders for settings and that was a common practice.

Review of the History and Physical dated 12-26-20 stated, "66-year-old morbidly obese white male with a past medical history of multiple allergies, coronary atherosclerosis, myocardial infarction, hypertension, type 2 diabetes mellitus, and obstructive sleep apnea presented with above chief complaint. Reports increasing shortness of breath x2 days. He was recently diagnosed with COVID-19 and discharged from the ED on Levaquin. EMS reported to his home today secondary to shortness of breath and found his O2 saturations in the 60s on his CPAP. Associated symptoms include fever, chills, cough, myalgias, lethargy. Denies sore throat, headache, chest pain, palpitations, abdominal pain, diarrhea, urinary symptoms.
**Arterial Blood Gases**
PHBLD 7.359 PCO2 28.6 (L) PO2 302.4 (H) HCO3 15.8 (L) BEX -8.5 (L) O2SAT 99 (H) FIO2 100
TEMP 37 DEVICE Bipap PEEP 8 PIP 22 RR 14."
The physician had put in settings for a bipap in his H&P but there were no physician orders for the Bipap or settings. Staff #4 and #6 confirmed the findings on 9/16/21.

Review of the RT notes on 12/26/20 at 20:57 (8:57PM) revealed Patient #13 was on "BIPAP "full face med mask" ventilator type V-60, Ventilator mode was (BIPAP) with respirations set at 14." There was no physician order for Bipap settings.

Review of the Clinical Documentation Report dated 12/27/20 at 15:31 (3:31PM) the RT charted, "put pt. on VAPOtherm per RN request, Pt saturation low to 70%. Pt back on Bipap." There was no documentation that the RT received a physician order to remove the Bipap or had an order to place on the Vapotherm. There was no found documentation that the physician was even aware of the patients change in condition. According to Vapotherm it is a "device that is mask-free non-invasive ventilation, thus enabling the technology to be used in patients requiring support with CO2 ventilation. High Velocity Nasal Insufflation utilizes a small-bore cannula and circuit that facilitates more efficient dead space washout with resultant improvement in ventilation efficiency."

Review of the Nurses Notes Assessment on 12/28/20 at 8:00AM stated Patient #13 was oriented x3. He was on telemetry for heart monitoring and was still on Bipap. The nurse documented on 12/28/20 at 12:00PM and 4:00PM that Patient #13 was still on Bipap.

Review of the Clinical Documentation Report dated 12/28/20 at 1555 (3:55PM) the RT documented that Patient #13 was on Bipap and documented settings.

Review of the Clinical Documentation Report dated 12/28/20 at 16:19 (4:19PM) the RN documented," called to room by charge nurse, _____ (charge nurse) for change reported from war room (telemetry observation). Charge nurse found pt. with no pulse or respirations, called code blue and began CPR. See code blue form. Time of death 1643 (4:43PM). _____ (Staff # 40) to notify family." At 1802 (6:02PM) telemetry tech had documented, "Patient had agonal beats, then was SB 30's. Patient went into Asystole. Compressions started at 16:22 (4:22PM). Patient was taken off telemetry at 1643 (4:43PM)." There was no further nursing documentation of the patient's condition before the code. Review of the code blue form stated "pt with unwitnessed arrest. CPR in progress."

Review of the death summary signed by staff #40 on 12/29/20 8:13AM stated, "At 1620, Telemetry tech called charge nurse to check on patient. When nurse went into room, patient found to be not breathing and pulseless. Code blue was initiated, and CPR was started. Patient was intubated, Epinephrine was pushed IV every 3 minutes, Bicarb multiple times and Calcium. No organized rhythm was achieved and after 25 minutes patient was pronounced deceased." There was no other physician progress note found describing the patients code or condition.

An interview was conducted on 9/16/21 in the afternoon. Staff #40 stated that he was a physician assistant and was in the facility when the code blue was called. Staff #40 stated "I remember this case very well. I led the code blue because the in house physician was busy in another code." Staff #40 confirmed that the death summary was his only documentation of the code. Staff #40 confirmed that Patient #13 was found without his Bipap mask on. The patient had pulled off his mask and was found by the nurse. Staff #40 confirmed he did not document about the mask being off. Staff #40 stated, "I don't think anything was written about the Bipap. Maybe I should have written that." Staff #40 confirmed he was not sure if an incident report was filled out or if anyone in Risk was aware.

An interview was conducted with Staff #6 on 9/16/21. Staff #6 stated that there was no incident report nor was there anything reported to Risk concerning Patient #13.


C. An observation tour was conducted on the Designated COVID Floor on 9/15/2021. Staff #8 toured the 2 second floor (Designated COVID floor) with the surveyor on 9/15/21 in the afternoon. The patients were at different levels of COVID infection. There were patients on Bipap, Airvo or Vapotherm, and some just on O2. The patient rooms had heavy wooden doors and some were shut. Two rooms were found with the door closed and the patients were on Bipap. There was no evidence that any system had been in place to monitor Bipap alarms or any patient with a respiratory device. Staff #6 confirmed the findings.

An interview with Staff #3 on 9/16/21 revealed she was not aware of the issue with Bipaps and alarms. Staff #3 had no performance improvement or quality data concerning safety issues with Bipap. Staff # 3 stated she had only been in her position for a short time.

An interview was conducted with Staff #2 on 9/21/21 in the afternoon. Staff #2 was asked if he was aware of the death of Patient #13 and was there any plans or actions put in place to prevent a patient death due to inability to hear alarms on patient equipment. Staff #2 stated that there were conversations over the last year over alarms and how to identify alarms, but he was unaware of Patient #13. Staff #2 confirmed there had been no changes put in place.



D. A review of Patient #9's medical record revealed the following:
Patient #9 was a 74-year-old male who presented to the Emergency Room (ER) on 8/31/2021. Patient #9 was subsequently admitted to the facility on 8/31/2021 at 12:48 PM with a diagnosis of Acute COVID Pneumonia.

A review of the Staff #43's (NP) order was as follows:
"9/01/2021 12:43 PM PT Eval and Treat"

A review of the documents titled, "Therapy-Physical Therapy Notes Acute" documented by Staff #21 (PT) was as follows:

" ...9/02/2021 10:52 AM

Subjective:
PT reviewed pt's chart and continued with skilled PT tx (treatment) as there are no contraindications to preclude tx at this time. Per RN, pt (patient) is stable and pt verbally agreeable to PT tx. Patient presents supine with HOB (head of bed) elevated on 7 LPM (Liters per minute) HFNC (high flow nasal cannula) without c/o (complaints of) pain on this date, PT/OT co-tx.

Therapeutic Activities
Sit to stand Stand to sit Rolling Sit to Supine Supine to Sit Bed to chair Comment: 7 LPM (liters per minute) with Spo2 >94% at rest supine with HOB (Head of Bed) elevated Min A (Minimal Assist) for supine > sit desaturation to 85% EOB (End of Bed) Mod A (Moderate Assist) for transfer OOB (Out of Bed) to recliner desaturation to 74% increase to 10 LPM desaturated further to 62% pt recovered to >90% in supported sitting with PLB and B LE (Bi lateral Lower Extremities) elevated Pt able to be titrated to 8 LPM with Spo2 at 90%

Distance
Pt participated in 4 side steps at Mod A from EOB>recliner on 7 LPM with desaturation EOB at 85% with transfer/gait OOB to recliner with desaturation 74% with increase 10 LPM with further desaturation to 62%, followed by PLB and recovery to 90% and ability to titrate down to 8 LPM with SpO2 at 90%.

Comments
Pt has generalized deconditioning with decrease in B LE and UE (upper extremities) strength, is Min A for supine to sit and Mod A for STS (sit to stand) and transfer OOB with O2 initially at 94% on 7 LPM at rest, desaturation to 62% recovery to greater than 90% and ability to titrate down to 8 LPM ..."

During a review of the therapy notes dated 9/02/2021 by Staff #21 (PT), this surveyor could not determine if Staff #21 titrated the oxygen flow rate greater than 10 LPM when Patient #9 "desaturated further to 62%." No documentation was made by Staff #21 that the Physician was notified of Patient #9's oxygen level and increase in Oxygen flow rate at the conclusion of the Physical Therapy. Staff #21 (PT) documented "RN (Registered Nurse) notified" but it was unclear what was reported to the RN.

" ...9/04/2021 6:53 AM

Subjective
PT reviewed pt's chart and continued with skilled PT tx as there are no contraindications to preclude tx at this time. PER RN, pt is stable and pt verbally agreeable to PT tx. Pt presents supine with HOB elevated on AirVo (a generator used to deliver warmed humidified gases of oxygen concentration of 2-60 liters per minute) at 15 LPM at 40% with Spo2 at 84%, increased to 25 LPM at 60% (as AirVo noted to be on pediatric mode upon entering the room, and RT (Respiratory Therapy requested to assist in transitioning off of pediatric mode in the event requiring to increase supplemental O2 (oxygen) needs during tx) Pt able to recover to >90% on 25 LPM at 60%. Pt has no c/o pain on this date.

Therapeutic Activities
Sit to Stand Stand to Sit Rolling Sit to Supine Supine to Sit Bed to Chair Toilet Transfer
Comment: AirVo at 15 LPM at 40% with SpO2 at 84% supine with HOB elevated Increased to 25 LPM at 60% with increase in SpO2 >90% prior to mobility Min A for bed mobility supine > sit Min A for STS and transfer to BSC Min A for doffing (removing) underwear Pt had large BM and urinated Min A for STS from BSC and Dependent for perianal care and Min A for donning (putting on) underwear Min A for transfer BSC > EOB (end of bed) > recliner desaturation to 54% with quick recovery to > 78% with supported sitting, PLB and B LE elevated 3 minutes to recover to 88-90% RT switched off AirVo and onto HFNC at 15 LPM w SpO2 at 92% upon PT dismissal and RT left in room with pt.

Comments
Pt continues to be limited with mobility d/t (due to) desaturation to lowest of 54% while on AirVo at 25 LPM at 60% with performing mtpl (multiple) transfers and utilization of BSC (bed side commode) for BM. Pt is Min A for mobility, and requires 3-5 minutes of RB (rest breaks) to recover to >90%. Pt left on 15 LPM HFNC with SpO2 at 92% and RT in room with pt ..."

During a review of the therapy notes dated 9/04/2021 by Staff #21 (PT), this surveyor could not determine who increased the high flow oxygen from 15 LPM to 25 LPM prior to beginning physical therapy. This surveyor could not determine if the Respiratory Therapist (RT) was in the room during the entire therapy session. No documentation was made by Staff #21 (PT) if the MD was notified that the AirVo was on pediatric mode prior to therapy or that Patient #9 required an increase in the oxygen flow rate during therapy. AirVo settings cannot be adjusted without a Physician Order. No Physician order was in the medical record for PT to titrate the oxygen flow rate. Staff #21 (PT) documented "RN notified" but it was unclear what information the RN was notified of. This surveyor could not determine if the RN was notified of the changes in the patient condition, the increase in the oxygen flow, or just if the therapy was complete.


" ...9/7/2021 13:55 (1:55 PM)
Subjective
PT reviewed pts chart and continued with skilled PT tx as there are no contraindications to preclude tx at this time. Per RN pt is stable and pt verbally agreeable to PT tx. Pt presents supine with HOB elevated on AirVo 35/80% without c/o pain on this date, and PT/OT co-tx on this date.

Therapeutic Activities
Sit to Stand Stand to Sit Rolling Sit to Supine Supine to Sit Bed to Chair Comment: Pt initially
At 35 LPM at 80% Min A for supine > sit Min A for STS Min for step to transfer to recliner desaturation to 74% requiring max AirVo at 60 LPM at 80% with extremely long time to recover to >90% with participating in BADL's pt exhibited desaturation to 86% requiring further prolonged recovery to > 90% PT/OT unable to titrate down d/t pt unable to maintain SpO2 > 90% without 60 LPM at 80%.


Comments
Pt continues to be severely limited with mobility d/t desaturation to lowets (sic) of 74% on AirVo at 35 LPM at 80% with Min A for transfer and 5 steps of gait with B HHA. Pt requires increase in AirVo to 60 LPM at 80% and very prolonged period of time to recover to 89-90% and inability to tolerate 02 weaning at this time ..." (sic)

During a review of the therapy notes dated 9/07/2021 by Staff #21 (PT), this surveyor could not determine if the MD was notified of Patient #9's condition and the need for an increased oxygen flow rate during therapy. No Physician order was in the medical record for PT to titrate the oxygen flow rate. Staff #21 (PT) documented "RN notified" but it was unclear what was reported to the RN.




A review of Patient #6's medical record revealed the following:

Patient #6 was a 64-year-old female presented to the

Based on record review and interview the facility failed to ensure the Quality Department was identifying issues and developing effective performance improvements concerning patient care, safety, staffing shortages, changes in treatments, supply issues and reporting from all departments to promote safety and quality of care.

Refer to Tag A0283

Based on review and interview the facility failed to ensure that Quality was identifying issues concerning patient care, safety, staffing shortages, changes in treatments, and reporting from all departments to promote safety and quality of care.

Review of the Quality Improvement Program revised 8/2021 stated, "III. PURPOSE:
The Quality Improvement Program is designed to provide a systematic and organized mechanism to promote safe and quality patient care and services. Through an integrated, interdisciplinary process, patient care and services shall be continuously monitored and evaluated to promote optimum outcomes.

The organization has the responsibility to design, measure, assess, and improve performance and patient safety. Ultimate authority and accountability for the quality and safety of patient care and services lies with the Governing Board and is delegated through the Quality Improvement Program to the Medical Staff, Administration and staff of the hospital.

IV. PHILOSOPHY:
The mission of the hospital is based upon a comprehensive system that allows for the implementation of continuous improvement through the following:
o The recognition that care and services can be improved through collaborative efforts between all departments and professions within the hospital.
o The recognition that all individuals are responsible for quality of care/services, patient safety, and performance improvement.
o The recognition of a need for competence, motivation, and willingness to bring quality into daily work activities.
o Recommendations to resolve problems and opportunities to improve the quality and
safety of patient care and services.
o Assessment of the effectiveness of actions taken by initiation or ongoing monitoring.
o Emphasis on education rather than punitive measures."

The facility was given an Immediate Jeopardy citation in 2019 due to no physician orders for patients on Ventilators. The QAPI department was collecting data and monitoring quality on the ventilators since 2019.

Review of patient charts #1, #2, #6, #11, and #12 had on a Bipap with no physician orders for Bipap or had no orders for Bipap settings.

An interview with Staff #6 and #8 was conducted on 9/14/21. Staff #8 stated that she was collecting the data for orders on ventilated patients but was not following patients on Bipap,( According to the NIH "A Bilevel Positive Airway Pressure (BiPAP) is a positive airway pressure device used to assist a critical patient with breathing that requires specific settings to ensure the safety of all patients. These specific settings include; Inspiratory positive airway pressure (IPAP), Expiratory positive airway pressure (EPAP), FiO2 (the fraction of inspired O2 in %), and Respiratory Rate are the most common settings used.) before starting treatment on patients.)
Staff #8 stated that she was not aware of any issues with the Bipaps or that Respiratory Therapists (RT's) were determining settings without physician orders or guidelines.

Staff #6 stated that the 2019 survey prompted a review of the issues on why there was no orders for ventilated patients. Staff #6 stated "Yes, we remember and at that time we determined that it was a computer problem. In the physician orders for ventilator settings there is a space for settings to be entered. There is not a hard stop for them to be reminded to complete that part of the order. That is one of the items we monitor through QAPI. I have talked to Corporate about this several times. The problem is that we cannot set a hard stop for the physicians to complete that area. The computer would place a hard stop on every physician order entered. It was then determined that we would not be implementing a process for this. We entered information into a space on the ventilator orders that reads, "Settings are required" to remind the physicians that this information has to be entered. This is information is also on the BIPAP orders, but we do not monitor those orders through QAPI like we do the vent orders."

Staff #3 confirmed there was no PI process in place to fix the identified problem with the hospitals software to create a hard stop on physician orders. This would ensure the physician had his orders completed for Ventilators, Bipap, Vapotherm, or Airvo settings. Staff #3 stated she was not aware there was a problem with the Bipap, Vapotherm, or Airvo orders or settings.

An interview with Staff #18 on 9/15/21 revealed she had not been reporting to QAPI for several months. Staff #18 and was unable to tell me when she last reported to QAPI. Staff #18 had reported the Staffing issue to Staff #2 to report to QAPI and Staff #2 was aware of the ventilator shortage in August. Staff #18 stated that when the ventilators got in a critical mode Staff #2 had to call into RAC for help.

Review of the QAPI meeting minutes for August revealed there was no mention of a ventilator shortage, no PI process was in place to make sure ventilators were accessible, or a plan in place.

An interview with Staff #2 on 9/16/21 confirmed there was no evidence of PI process for staffing shortages in Nursing, Respiratory Therapy or any other department.

Staff #2 and Staff #3 came into the conference room and brought in a large notebook of meeting minutes. Staff #3 stated that it was meeting minutes where they talked about all these issues (staffing, ventilators, needs of the hospital) but had not implemented them or reported this information any further.

An interview with Staff #2 was conducted on 9/21/21in the afternoon. Staff #2 stated that the administration had conversations on better ways to ensure staff could hear vital alarms (BIPAP, IV's, bed alarms) behind closed doors but there was no PI process in place to ensure patient safety.

An interview was conducted with Staff #3 on 9/15/21. Staff #3 stated that she had just took over the QAPI department in May 2021. Staff #3 stated that she had no prior experience as a QAPI Director. Staff #3 was the Case manager Director before she took her current position. Staff #3 stated that she had no PI processes for staffing shortages, incentive programs that had been recently put in place to retain staff, ventilator needs, or falls. There was no PI for COVID patients concerning limited visitations, COVID patients sharing rooms, Staff testing for COVID or what was being done for COVID positive staff, divert and emergency status of the hospital, continuing elective surgeries and how that was impacting staffing or COVID infections. There was no PI in place to monitor what departments had not reported to QAPI or why.

Based on observation, interview, and document review, the facility failed to ensure a clean and sanitary environment in 2 (Emergency Room and 2nd floor) of 4 areas observed to mitigate the spread of COVID-19.

Findings Include:

Emergency Room

During an observation tour on 9/13/2021 at 1:05 PM with Staff #6. #8, #9 and Staff #33 the following was observed:

Upon entering the Emergency Room (ER) two nurses were observed at the Nurses Station facing a computer and conversing among themselves with their mask noted down under their chin. Staff #6 instructed them to place them on their faces correctly.

A large white board was observed across from the nurses station with Room Numbers and the Nurses name that was assigned to that room. Down past the white board are patient rooms. Room #6, # 10, #11, and #12 was noted to not have a sign on the outside of the door for isolation precautions. Room #12 was noted to have a white laminated sign that was blank hanging on the outside of the door. Across from the patient rooms was a large white cabinet with a sign that read, "Isolation Cart (PPE)". The top of the cabinet has the capability to be locked by a combination. This surveyor was able to open the cabinet and noted there was supplies such as PPE (Personal Protective Equipment) stored inside. Only one gown was noted in the bottom drawer. There was a limited supply of gloves, no goggles, and no N95 masks. Staff #33 confirmed the findings. Staff #33 was asked who was responsible for stocking the cart with supplies. Staff #33 stated, "We all do it when it needs to be done.".

An interview was conducted on 9/13/2021 in the afternoon with Staff #33. Staff #33 was asked if there were any COVID positive patients in the rooms at this end of the hall. Staff #33 stated, "Yes, and some are PUI (persons under investigation) that we are waiting for the results of their COVID test. Staff #33 was asked if Rooms #6, #7, #10, #11, and #12 were COVID positive patients. Staff #33 stated, "Yes, Room #6, #7, #10, and #11 are all positive but, Room #12 is not. The results came back as negative." Staff #33 was asked why there was no isolation precautions sign placed on the doors of the COVID positive patients. Staff #33 stated, "We have a communication board across from the nurses station that gives that information." An observation was made of the communication board with Staff #33. Room #6, #7, #10, #11, and #12 all had a positive sign in red by the room number. Staff #33 erased the positive sign by Room #12 stating, "The results are negative for this patient now." Staff #33 was asked who was responsible for keeping the board current. Staff #33 stated, "Well all nurses change the information when they can but there is no one single person responsible for it."

An interview was conducted with Staff #25 on 9/13/2021 at 1:40 PM. Staff #25 was asked how she knew if a patient was COVID positive before entering the room. Staff #25 stated, "There should be a sign on the door for precautions but sometimes there isn't. Sometimes we don't know until we get into the room or the nurses tell us after we are already in there." Staff #25 was asked if she looked at the communication board when she came to the ER. Staff #25 stated, "I really don't know how to read that board and the information on it. Sometimes we are behind on our treatments and we don't look at it. If the patient is positive for COVID then there should be a sign on the door and a lot of times, there isn't." Staff #25 was asked where she got her PPE before treating a patient that was COVID positive. Staff #25 proceeded to point to the general supply storage room. Upon opening the supply room door Staff #25 pointed to where the gowns were kept. Staff #25 and #33 confirmed there was only shoe coverings and blue bonnet head coverings in the bin. Staff #25 was then asked if she ever obtained her PPE from the storage cabinet in the hallway. Staff #25 stated, "Well it is locked most of the time." Staff #25 was asked how she got into it if she needed the PPE. Staff #25 stated, "We have to find someone to open it." Staff #25 was asked how she obtained her PPE if there was an emergency at the other end of the hall. Staff #25 stated, "We come to the supply room and get it, or we have someone get it for us."

Staff #33 confirmed they only had the one storage cabinet for PPE in the ER.

During an interview on 9/13/2021 after 4:00 PM, Staff #10 confirmed all COVID positive and PUI patients should have a transmission-based sign on the door, specifically a Respiratory Isolation sign.


Second Floor-COVID Unit

An observation tour was conducted on 9/15/2021 at 4:00 PM with Staff #6, #8, and #9. Staff #6 and #8 confirmed the 2nd floor was all COVID patients.

The Supply Room door in the hallway was noted to be propped open with a trash can. Inside the supply room was a box fan, 2 portable metal carts, a shower chair, an uncovered linen cart used to store linens for patients, a portable covered cart for transportation of supplies, and general patient supplies. The general patient supplies consisted of urinals, foley catheters, IV supplies, dressings for wounds, Kleenex, surgical masks, ice packs, basins, and some sterile basic packs for bedside procedures. This was not an all-inclusive list. There was no indicator on the shower chair, box fan, or the portable metal carts indicating if the equipment was clean or dirty. An overflowing laundry bin was observed. Staff #8 could not confirm or deny if the linen was clean or dirty. The uncovered linen cart stored clean gowns, sheets, towels and wash cloths for patient use. All items were readily available for patient use. The supply room was left open and unattended by staff. This exposed the supplies and equipment to COVID-19 and other infectious diseases by means of cross contamination by employees. Down the hallway, against the wall, was a large uncovered rolling bin used for trash that was overfilled with full trash bags from patients rooms.

The door to Patient room #214 was observed open. On the door of Patient room #214 was a hanging metal rack used for PPE supplies. One hanging metal rack was used for two rooms that are side by side. Patient room #218 was noted to have a Respiratory Isolation sign on the door frame. Patient Room #219 did not have a Respiratory Isolation sign hanging on the door. Hanging on the door frame of Patient Room #219 was a clear full-face shield. There was no way to determine if the face shield had been cleaned. There was no hanging metal rack on the door or PPE cart readily available to enter the two patient rooms in an emergency.

A bed was noted in the hallway pushed against the wall. Employee belongings were on top of the mattress along with partially opened patient supplies. Staff #6 and #9 could not confirm or deny if the bed had been disinfected before leaving it in the hallway. Also, stored along the wall was a 5-shelf metal cart. On the metal cart was 5 Cogent monitors (a hemodynamic monitoring system), cables, cords, and a plastic bin used to hold new patient cables for the monitors. Only 1 of the 5 monitors had a tag confirming that it had been disinfected. Nursing Staff on this unit stated there was no storage space for the shelf anywhere else and they rarely used the monitors. They "assumed" they were all clean but could not confirm.

Staff #37 was observed exiting a patient room without doffing (removing) her dirty PPE. Staff #37 proceeded to enter Patient Room #224 and not donning (putting on) clean PPE. This was done in front of the surveyors. Staff #37 stated, "She was trying to remove family from that room."




A review of the document titled, "COVID_19 Transmission Based Precautions Policy IC-3.130" with an effective date of 5/20/2021 was as follows:

" ...I. PURPPOSE:

Use specific Droplet Contact or Airborne Contact isolation as recommended
for patients known or suspected to be infected with Coronavirus Disease
2019 (COVID-19).

II. POLICY:

All Longview Regional Medical Center Personnel whenever indicated will
routinely practice COVID-19 Isolation Precautions.

III.PROCEDURE:

The following strategies for COVID-19 Transmission Based Precautions as
recommended by the Centers for Disease Control (CDC) will be adhered
to in order to protect patients and personnel.

Specific Requirements:
...
7. Place the Respiratory Isolation sign below (a photo of the facilities sign)
To designate a COVID patient and proper PPE ..."


Staff #6, #8, and #9 confirmed the above findings.









32143

Review of the complaint revealed Respiratory Therapist's (RT) were carrying metered dose inhalers (MDI's) in their pockets from room to room. MDI's are pressurized canister of medication in a plastic case with a spacer and mouthpiece.

An interview was conducted on 9/13/21 with Staff #12,25, and 29. RT staff was asked if they left the multidose canaster in the patient's room, in a medication area, or if they were carrying the canisters in their pockets from room to room? Staff #12, #25 and 29 all stated that they have to keep the canisters in their pockets. Staff #25 stated that the pharmacy will not get them MDI's to leave in the patient rooms even though the orders state to leave with the patients. Staff #25 pulled a canister from her uniform pocket. Staff #12, #25 and #29 confirmed they were given no choice and wiped the canisters down with a sanitized wipe, but the same canister went from patient to patient rooms including COVID and NON-COVID. The RT's stated they had no instructions on how to clean the device to ensure they were not contaminated and could not ensure they were not contaminated. The RT's added up their breathing treatment assignments and found they were running around 195+ treatments per shift.

Review of the policy and procedure "Metered Dose Inhaler Common Canister Policy" stated, "The Respiratory Therapist (RT) will use a MDI attached to the valved holding chamber to administer the MDI therapy and provide instructions for use to the patient. The MDI will be kept in the Respiratory Therapy department when not in use. MDls may not be kept at the patient bedside. Each MDI may then be used with the valved holding chamber on multiple patients without concern for patient to patient contamination.

For administration to a patient, the RT will take the MDI to the patient's room, wipe the actuator tip with an alcohol prep pad, attach the MDI to the valved holding chamber, and administer the correct number of puffs. The MDI should then be removed from the valved holding chamber, the actuator tip should be re-wiped with an alcohol pep pad, and the MDI should be returned to the Respiratory Therapy department. This process should be repeated for subsequent patients.

This practice allows patients to be charged for what they actually receive from the MDI versus the entire MDI. The valved holding chamber may be billed as a separate item.Patients under isolation precautions may be excluded from the common canister policy."

An interview was conducted with Staff #19 on 9//14/21. Staff #19 stated that the pharmacy had instructed the MDI to be used on multiple patients, but Staff #19 stated he was not aware it was taken into COVID and NON-COVID rooms. Staff #19 confirmed it should not be in the RT's pockets and taken into rooms of patients in isolation. Staff #19 stated that the he was not sure why the physician orders stated to leave in patient rooms other than they were in isolation.