HospitalInspections.org

Based on interview and document review, the facility failed to have the policies and procedures guiding respiratory therapy services reviewed and approved by the Medical Director of Respiratory Services. Failure to assure services are delivered in accordance with medical staff directives places patient's at risk for unsafe care.

Findings include:

Of the respiratory specific policies and procedures reviewed by this investigator, including the newly revised Heliox policy, eight were not approved by the Medical Director of Respiratory Services.
? Policies and procedures:
o Helium Oxygen Therapy (pre and post incident)
o Plan for Provision of Care - Respiratory Therapy
o Lung Protective Ventilation Orders
o Measurement of Lung Volumes
o Adult Continuous Mechanical Ventilation
o Adult Ventilator Weaning Guidelines - APPROVED BY MEDICAL STAFF
o Medical Equipment Management Plan
o Spirometry - APPROVED BY MEDICAL STAFF
o Arterial Puncture for Blood Gas Analysis
o Arterial Blood Gas (ABG) Critical Values - APPROVED BY MEDICAL STAFF
o Proper Handling of Soiled Respiratory Equipment
o Adult Ventilator Weaning Guidelines - APPROVED BY MEDICAL STAFF