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Based on review of facility documents, medical records (MR), credential files (CF), and staff interview (EMP), it was determined the facility failed to ensure a physician had privileges for ventilator management for one of six credential files reviewed (CF2).

Findings include:

Review on July 10, 2024, of the "Medical Staff Bylaws Of Regional Hospital Of Scranton," dated November 29, 2023, revealed "...4.2 Active Staff ...4.2(b) Prerogatives ... (2) To exercise only such delineated clinical privileges as are granted to him/her pursuant to Article VII; ... 6.3(e) Description of Initial Clinical Privileges Medical Staff appointments or reappointments shall not confer any clinical privileges or rights to practice in the Hospital. Each Practitioner who is appointed to the Medical Staff of the Hospital shall be entitled to exercise only those clinical privileges specifically granted by the Board. ... ARTICLE VII - Determination Of Clinical Privileges 7.1 Exercise Of Privileges Every Practitioner or AHP providing direct clinical services at this Hospital shall, in connection with such practice and except as provided in Section 7.5, be entitled to exercise only those clinical privileges or services specifically granted to him/her by the Board. Said privileges must be within the scope of the license authorizing the Practitioner or AHP to practice in this state and consistent with any restrictions thereon. The Board shall approve the list of specific privileges and limitations for each category of Practitioner and AHP, and each Practitioner or AHP shall bear the burden of establishing his/her qualifications to exercise each individual privilege granted. ..."

Review on July 10, 2024, of CF2, revealed CF2's appointment was January 25, 2023, until January 24, 2025. CF2 was granted nephrology privileges.

Interview on July 10, 2024, with EMP9, at approximately 1:10 PM, confirmed the above findings.

Review on July 10, 2024, of MR2, revealed a verbal order from CF2 for ventilator settings on July 1, 2024, at 13:39 PM.

Interview on July 10, 2024, with EMP3, at approximately 1:30 PM confirmed the above findings.

Continued interview on July 10, 2024, with EMP9, at approximately 1:45 PM, confirmed CF2 does not have privileges for ventilator care.

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure verbal orders were co-signed by a physician within 24 hours for four of four medical records reviewed (MR1, MR2, MR3, and MR4).

Findings include:

Review on July 10, 2024, of facility, "Regional Hospital Of Scranton Rules And Regulations," approved November 29, 2023, revealed, "...Verbal Orders Verbal orders are discouraged and should be reserved for those situations when it is impossible or impractical for the practitioner to write the order or enter it in a computer. Verbal orders must comply with the following criteria: ...d. All verbal orders must be signed by the ordering practitioner or another practitioner involved in the patient's care within 24. ..."

Review on July 10, 2024, of MR1, revealed a verbal order was given by CF1 on June 29, 2024, at 16:08 PM to change the FIO2 to 50% and wean per respiratory vent management protocol, wean O2 to keep sats 94-95%. No documentation the verbal order was co-signed by a physician within 24 hours.

Continued review of MR1, revealed a verbal order was given by CF1 on July 1, 2024, at 16:38 PM, for Ventilator Mode SIMV/IMV Rate 12 Tidal volume (ml) 450 FIO2 30 Peep (cmH2O) 5 Pressure Support (cmH2O) 5 Constant Indicator Yes Special Instructions wean per resp vent management protocol, wean O2 to keep sats 94-95%. No documentation the verbal order was co-signed by a physician within 24 hours.

Interview on July 10, 2024, with EMP3, at approximately 1:20 PM, confirmed the above findings.

Review on July 10, 2024, of MR2, revealed a verbal order was given by CF1 on June 30, 2024, at 08:04 AM, for Ventilator Mode AC Rate (BPM) 24 Tidal volume (mL) 600 FIO2 100 PEEP (cmH2O) 5 Constant Indicator Yes, may titrate FiO2 to keep O2 saturation equal to or greater than 92%. No documentation the verbal order was co-signed by a physician within 24 hours.

Interview on July 10, 2024, with EMP3, at approximately 1:40 PM, confirmed the above findings.

Review on July 11, 2024, of MR3, revealed a verbal order was given by CF1 on June 25, 2024, at 16:02 PM, for Ventilator Mode CPAP FIO2 40 Peep (cmH2O) 5 Pressure Support (cmH2O) 5 constant Indicator Yes Special Instructions Adjust FiO2 to maintain O2 saturation greater than or equal to 92%. No documentation the verbal order was co-signed by a physician within 24 hours.

Continued review on July 11, 2024, of MR3, revealed a verbal order was given by CF1 on June 30, 2024, at 11:13 AM, for Ventilator Mode AC Rate (BPM) 18, Tidal volume (mL) 450 FIO2 30 PEEP (cmH2O) 5 Constant Indicator Yes Difference in Minutes -1. No documentation the verbal order was co-signed by a physician within 24 hours.

Interview on July 11, 2024, with EMP3, at approximately 9:30 AM, confirmed the above findings.

Review on July 11, 2024, of MR4, revealed a verbal order was given by CF1 on July 4, 2024, at 19:16 PM, for Ventilator Mode AC Rate (BPM) 18 Tidal volume (mL) 440 FIO2 40 PEEP (cmH2O) 5 Constant Indicator Yes Difference in Minutes -1. No documentation the verbal order was co-signed by a physician within 24 hours.

Continued review of MR4, revealed a verbal order was given by CF1 on July 5, 2024, at 14:16 PM, for Ventilator Mode CPAP FIO2 40 PEEP (cmH2O) 5 Pressure Support (cmH2O) 5 Constant Indicator Yes. No documentation the verbal order was co-signed by a physician within 24 hours.

Interview on July 11, 2024, with EMP3 confirmed the above findings for MR4.