HospitalInspections.org

Based on QAPI program review and interview, the hospital's governing body failed to ensure there was a mechanism in place to evaluate the quality of each contracted service to ensure that each contracted service was provided in a safe and effective manner. This deficient practice was evidenced by the hospital's governing body's failure to include all contracted services in the hospital wide QAPI program.

Findings:

Review of the hospital's QAPI program documentation, presented as current by S4RN (QAPI Director), revealed no documented evidence that the following contracted services were included in the hospital's QAPI program: linens,Stericycle (biohazardous waste disposal service), patient transportation services, and the hospital's oxygen supplier.

In an intervew on 2/3/16 at 10:30 a.m. with S4RN, she confirmed the above referenced contracted services and maintenance were not included in the hospital's QAPI program.

Based on record review and interview, the hospital's governing body failed to ensure the effective operation of the grievance process. This deficient practice is evidenced by failing to have documented evidence of an investigation of grievances for 5 (#R1, #R2, #R3, #R4, #R5) of 5 grievances reviewed from a total of 28 grievances.

Findings:

Review of the hospital policy titled Patient Complaint/Grievance Policy revealed in part:
Grievance: Written or verbal requests by a patient or designated representative to have the facility formally review the patient's concern or objection about the quality or appropriateness of patient care. Generally a grievance would require an investigation and/or may require management level personnel to resolve the grievance.

Review of the grievance log for 2015 and 2016 presented by S2DON revealed patients had written 11 grievances in 2015 and 17 grievances in 2016. Review of grievances written on 3/10/15 by Patient #R1, 11/29/15 by Patient #R2, 11/18/15 by Patient #R3, 12/28/15 by Patient #R4 and 6/25/15 by Patient #R5 revealed no documentation of an investigation of the grievances.

In an interview on 2/2/16 at 1:40 p.m. with S2DON, he said he had not had any grievances in the past year. After review of the above mentioned grievances, S2DON verified he had no documented evidence of an investigation of the incident reports. S2DON said he considered the incidents complaints instead of grievances. S2DON also said he did not realize a written complaint was considered a grievance.

Based on record review and interview, the hospital failed to ensure the patient or their representative had the right to make informed decisions regarding their care. This deficient practice is evidenced by failing to disclose to patients that a physician was not present in the hospital 24 hours per day and seven days per week for 11 (#1- #11) of 11 patients reviewed.

Findings:

Review of the admission paperwork signed by the patients and the patients' handbook given to the patients on admission revealed no notification of physicians not being present in the hospital 24 hours per day and 7 days per week.

Review of the medical records for Patient #1- Patient #11 revealed no documented evidence of notification that there was not a physician in house 24 hours a day and 7 days per week.

In an interview on 2/2/16 at 1:20 p.m. with S2DON, he verified there was no notification given to the patients that there were not physicians in house 24 hours a day and 7 days per week.

Based on observation and interview, the hospital failed to ensure psychiatric patients received care in a safe setting as evidenced by multiple ligature risks in the patient's rooms and unsupervised common areas in the hospital.

Findings:
Observation of the patients' rooms on 2/3/16 between 9:15 a.m. and 10:00 a.m. revealed the following ligature risks:
a) Patients' beds in the 24 patients' rooms were metal framed with multiple ligature points.
b) Light fixtures above the sinks in the patients' bathrooms protruded from the wall.
c) Removable cords from the televisions to video equipment in the 3 unsupervised day rooms.
d) Fire alarm lights approximately 6 ½ feet from the floor were in rooms #11, #12 and the shower room. A metal casing covering wires from the light to the ceiling was separated from the wall enough to act as a ligature point.
e) Doors to restrooms and closets inside patients' rooms had hinges with spaces between them.
f) Faucets in the patients' bathrooms were elongated with protruding knobbed handles.
g) Vent with spaced grates in shower room in 2rd hallway.
h) Air conditioners in patients' rooms on 1st hall elevated in the walls with exposed electrical cords from the air conditioners to electrical boxes.
i) Drawers in built in cabinets in the patients' rooms that could be pulled out and used as ligature points.
j) Protruding faucet and handle of a bathtub in the shower room in 2rd hallway.

In an interview on 2/3/16 at 10:15 a.m. with S2DON, he verified the above mentioned structural features of the hospital were ligature risks.

Based on policy review, record review and interview, the hospital failed to ensure an allegation of alleged sexual abuse was reported to the Louisiana Department of Health and Hospitals for 1 (#R1) of 1 patient reviewed for potential abuse.

Findings:

Review of La R.S. 40:2009.20 revealed a health care facility must notify the Department of Health and Hospitals or the local law enforcement agency of any allegation of abuse or neglect occurring within the facility, within 24 hours of knowledge of the allegations.

Review of the hospital policy titled Alleged Patient Abuse, Neglect, Exploitation or Extortion, Policy Number: ADM 007, revealed in part:
2. Any person who reasonably believes or who knows of information that would reasonably cause a person to believe that a patient has been , is, or will be adversely affected by abuse or neglect, shall as soon as possible report the information to the Louisiana Department of Health and Hospitals.
11. Allegations regarding sexual misconduct by professionals will also be reported to the appropriate licensing board.

Review of an incident report dated 3/10/15 by Patient #R1 revealed she alleged sexual abuse by staff member S15MHT. Further review of the investigation of the alleged incident revealed it was never reported to the Louisiana Department of Health and Hospitals.

In an interview on 2/1/16 at 4:00 p.m. with S2DON, he said he did not report the allegation of sexual abuse against Patient #R1 to the Department of Health and Hospitals. He said he was not aware he had to report it to the state authorities.

Based on record review and interview, the hospital failed to ensure the Quality Assessment and Performance Improvement (QAPI) Program measured, analyzed and tracked adverse patient events. This deficient practice is evidenced by failing to analyze elopements by 2 (#R6,#R7) psychiatric patients.
Findings:
Review of the hospital ' s incident reports for 2015 and 2016 revealed 2 patients had eloped from the hospital in 2015. Further review revealed Patient #R6 had eloped on 7/9/15 and Patient #R7 had eloped on 11/22/15. Additional review revealed both patients had used the hospital's windows as a means of exit from the hospital.
Review of the hospital's QAPI data, presented as current by S4RN (QAPI Director), revealed no evidence to indicate that the elopements of Patients #R6 and #R7 had been evaluated through the hospital's QAPI program.
In an interview on 2/3/16 at 10:30 a.m. with S4RN, she verified the above referenced elopements had not been analyzed/included in the hospital ' s QAPI program.

Based on QAPI program review and interview, the hospital's governing body failed to ensure that the program reflected the complexity of the hospital's organization and services. This deficient practice was evidenced by the hospital's failure to include all departments and services , including those services furnished under contract or arrangement, in the hospital's QAPI program.

Findings:

Review of the hospital's QAPI program documentation, presented as current by S4RN (QAPI Director), revealed no documented evidence that the following contracted services were included in the hospital's QAPI program: linens,Stericycle (biohazardous waste disposal service), patient transportation services, and the hospital's oxygen supplier. Further review revealed no documented evidence that maintenance was included in the hospital's QAPI program.
In an intervew on 2/3/16 at 10:30 a.m. with S4RN, she confirmed the above referenced contracted services and maintenance were not included in the hospital's QAPI program.

Based on observation, interview, and QAPI program review the hospital's governing body failed to ensure the hospital-wide quality assessment and performance improvement efforts addressed priorities for improved quality of care and patient safety. This deficient practice was evidenced by failure to include patient safety risks observed (by surveyors) in the patient care environment (multiple ligature risks in the patient's rooms and unsupervised common areas in the hospital) and evaluation of patient food quality in the hospital wide QAPI program.

Findings:

Observation of the patients' rooms on 2/3/16 between 9:15 a.m. and 10:00 a.m. revealed the following ligature risks:
a) Patients' beds in the 24 patients' rooms were metal framed with multiple ligature points.
b) Light fixtures above the sinks in the patients' bathrooms protruded from the wall.
c) Removable cords from the televisions to video equipment in the 3 unsupervised day rooms.
d) Fire alarm lights approximately 6 ½ feet from the floor were in rooms #11, #12 and the shower room. A metal casing covering wires from the light to the ceiling was separated from the wall enough to act as a ligature point.
e) Doors to restrooms and closets inside patients' rooms had hinges with spaces between them.
f) Faucets in the patients' bathrooms were elongated with protruding knobbed handles.
g) Vent with spaced grates in shower room in 2rd hallway.
h) Air conditioners in patients' rooms on 1st hall elevated in the walls with exposed electrical cords from the air conditioners to electrical boxes.
i) Drawers in built in cabinets in the patients' rooms that could be pulled out and used as ligature points.
j) Protruding faucet and handle of a bathtub in the shower room in 2rd hallway.

In an interview on 2/3/16 at 10:15 a.m. with S2DON, he verified the above mentioned structural features of the hospital were ligature risks.

Review of the hospital's complaints/grievances for the last year revealed 18 complaints/grievances regarding the quality of food served at the hospital.

Review of the hospital's QAPI program, presented as current by S4RN (QAPI Director), revealed no documented evidence that patient safety risks observed (by surveyors) in the patient care environment (referenced above) and evaluation of patient food quality in the hospital wide QAPI program.


In an interview on 2/3/16 at 10:30 a.m. with S4RN, she confirmed the above referenced patient safety risks observed (by surveyors) in the patient care environment and evaluation of patient food quality were not included in the hospital's QAPI program. S4RN agreed the above referenced issues should have been included for evaluation in the hospital's QAPI program.

Based on record review and interview, the hospital failed to ensure the skill and competence of all individuals providing direct patient care had been evaluated as evidenced by failing to maintain documented evidence of skills competency evaluations for 3 (S7RN, S8LPN, S9LPN) of 3 direct patient care nurses' personnel records reviewed for competency .
Findings:
Review of the personnel files for S7RN, S8LPN and S9LPN revealed no documented evidence that an observation of competency in performance of job duties, including management of oxygen tanks, nasal cannulas, venti-masks, non-re-breather masks, hand held nebulizers, inhalers, application of restraints, use of the blood glucose monitoring device and administration of injections had been conducted.
In an interview on 2/2/16 at 3:30 p.m. with S4RN (ADON), she indicated the nurses perform a self-assessment for skills competency evaluations. She confirmed the hospital ' s nursing staffs' skills competencies were not evaluated by the DON or ADON after completion of orientation.
In an interview on 2/2/16 at 3:45 p.m. with S2DON, he confirmed the hospital had policies and procedures for management of oxygen tanks, nasal cannulas, venti-masks, non-re-breather masks, hand held nebulizers, inhalers, application of restraints, use of the blood glucose monitoring device and administration of injections. S2DON indicated skills competency check offs (return demonstrations) for the above referenced procedures were only conducted during orientation. He further indicated staff skills competencies were based upon self attestation after orientation and not observation/evaluation of skills performance.

Based on observation and interview, the hospital failed to ensure all patient medical records were properly stored in secure locations where they were protected from fire, water damage and other threats. This deficient practice was evidenced by storage of a total of 834 patient medical records (2013-2015) on open shelving, unprotected from fire and water damage.

Findings:


Review of the hospital policy titled Medical Record Availability, Policy Number: HIM 009, revealed in part: Procedure: 1. Records shall be kept on all patients admitted or accepted for treatment. c. The medical record is the property of this hospital and is maintained for the benefit of the patient, the medical staff and the hospital. The hospital shall safeguard information in the record against loss, defacement, tampering or use by unauthorized persons.


On 2/1/16 at 3:35 p.m. an observation was made of the hospital's medical record storage areas.The patient medical records were stored in 2 locations, onsite, at the hospital. The records stored in the medical records manager's office were housed on 4 open shelving units (each unit had 6 shelves). There were 472 patients' medical records (2014-2015) stored, uncovered, in the above referenced shelving units. The medical records office was noted to be sprinklered. An observation was also made of the medical records storage room located across the hall from the medical records manager's office. The room was noted to be sprinklered. 362 medical records (2013-2014) were observed on 2 open shelving units (one unit had 6 open shelves and the other had 7 open shelves). The above referenced observations were confirmed in interview, during the observation, on 2/1/16 at 3:40 p.m. with S3MRTech. She agreed the medical records in both the manager's office and the medical records storage room were stored in a manner that did not protect them from loss and or destruction.

Verified in interview with S3MRTech, during the observation, that the medical records were unprotected from loss. She indicated she is the custodian of the medical records. She said they had a plan in place to scan the medical records into the system, but she needs help to complete scanning them into the electronic system. She confirmed she is the only MR employee.

Based on Louisiana Administrative Code, contract review and interview, the hospital failed to ensure drugs and biologicals were controlled and distributed in accordance with applicable standards of practice, consistent with state law. This deficient practice was evidenced by failing to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist, before the first dose was dispensed, for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications.

Findings:

Review of the Louisiana Administrative Code, Professional and Occupational Standards,
Title 46: LIII, Pharmacist, Chapter 15, Hospital Pharmacy, §1511. Revealed in part:
Prescription Drug Orders
A. The pharmacist shall review the practitioner's medical order prior to dispensing the initial
dose of medication, except in cases of emergency.

Review of the hospital's contract with Consultant Pharmacy "A" revealed no provisions for
the Consulting pharmacist to review medications before the first dose was dispensed and
administered.

In an interview on 2/1/16 at 2:40 p.m. with S13LPN, she said the contracted pharmacy hours of operation were from 8:30 a.m. until 5:00 p.m. Monday through Friday, 8:30 a.m. through 4:00 p.m. Saturday and closed on Sundays and Holidays. S13LPN said if a patient was admitted when the pharmacy was closed the staff would obtain the medication from stock medications or the "emergency" medication kit. S13LPN said the emergency kit was the most common medications that may be given and not just medications used in an emergency. S13LPN said the staff did not have to get pharmacy approval before administering the medications to the patients.
In an interview on 2/2/16 at 10:45 a.m. with S14Pharmacist, he said he was director of the consulting pharmacy for the hospital. He verified there was no first dose review of medications by a pharmacist after pharmacy working hours or on holidays. S14Pharmacist said if a medication was ordered at night or on weekends it would be reviewed the next day retrospectively after the dose had already been dispensed.

Based upon record review and interview, the hospital failed to ensure the contract for laboratory services identified emergency "stat" laboratory testing related to the turn around times for collection, processing and the provision of the results. Findings:

Review of the laboratory contract revealed the contract failed to identify emergency laboratory testing and the turn around times when the laboratory results would be available.

Interview with S1Administrator on 02/01/16 at 3:10 p.m. confirmed the contract failed to identify emergency laboratory services.

Based on record review and interview, the hospital failed to ensure there was a full-time employee who served as director of food and dietetic service and who was qualified to be responsible for the daily management of the dietary services within the hospital.

Findings:

Review of the Hospital's Dietary Contract with an outsource agency revealed no documented evidence that it was the responsibility of the agency to provide a qualified individual to manage the daily dietary service at the hospital.

S1Administrator indicated S4RN had the serv-safe course and she was responsible for the management of the dietary services within the hospital.

In an interview on 02/02/16 at 3:45 p.m., S4RN indicated she did complete the serv-safe food course, but she was not the Dietary Manager of the Hospital.

In an interview on 02/02/16 at 3:45 p.m., S1Administrator confirmed the Hospital did not have a qualified individual in the position of Dietary Manager.

Based on observations, record review and interview, the hospital failed to have a dietitian who supervised the nutritional aspects of patient care as evidenced by the dietician failing to review and approve the patients' menus. Findings:

Review of the Hospital's Policy and Procedure titled, "Dietary Menus (DM 004 rev. 14)" presented by S2DON as being current read in part: The Dietary Departments' menus are planned on a 28 day, (4 week) cycle and are planned in accordance with those of the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council of the National Academy of Sciences.

In an interview on 02/03/16 at 8:00 a.m., S2DON reported that the Hospital had no cycle menu available for review. S2DON reported S10RD did not approve the menu and/or supervised the diets served at the Hospital.

Based on record review, observation and interview, the hospital failed to ensure ordered therapeutic diets were served in accordance with recognized dietary practices. This deficient practice was evidenced by failure of the hospital to ensure meals prepared by the contracted SNF(Skilled Nursing Facility) were prepared according to the ordered 1800 calorie ADA diet requirements.

Findings:

Review of the Hospital's Policy and Procedure titled, Diet Orders, policy #: DM 006 presented as current (2014) by hospital staff, revealed in part: The diet ordered must correspond with those outlined in the diet manual. Changes in the diet order should be written by the physician.

Review of the Hospital's Food Services Agreement with the SNF(Skilled Nursing Facility), Addendum A- Services and Fees revealed in part: The available meals are regular, no added salt, reduced concentrated sweets, and liberal renal diet. Hospital will choose from the main choice and alternate choice on (name of outsource food agency) menu for that meal. Further review revealed no option for an 1800 calorie ADA diet.

Review of the Hospital's diet list, dated 2/2/16, presented by S6MHT revealed there were 12 patients on therapeutic diets out of a total census of 24 patients. The therapeutic diets listed were as follows: 1800 Calorie ADA (6), 2000 Calorie ADA (2), Low Sodium (3) and Coumadin diet (1).

Review of the Medical Record for Patient #1 revealed he had been admitted to the hospital on 01/16/16 with a diagnosis of Diabetes Mellitus. Review of the Physician's orders for Patient #1 revealed upon admission a double portion diet was ordered. An order written on 01/17/16 revealed a change in Patient #1's diet to 1800 cal. ADA diet.

Observation of the lunch meal on 02/01/16 at 11:45 a.m. revealed the meal consisted of the following: Fried chicken (2 pieces), cheesy potatoes, fried okra, cornbread, peach cobbler, and juice. All patient trays contained the same type and amount of food.

Observation on 02/01/16 at 11:55 a.m. of Patient #1's meal revealed instead of an 1800 calorie ADA diet his meal consisted of 2 pieces of chicken, fried okra, cornbread, cheesy potatoes & peach cobbler. Patient #1 was given 2 additional servings of dessert (peach cobbler) by Patient #5 and another female patient. Continued observation of the lunch meal from 11:45 a.m. to 12:00 p.m. revealed no hospital staff was present in the dining area to monitor patients during lunch time.

Observation of the lunch meal on 02/02/6 at 12:15 p.m. revealed the meal consisted of the following: Beef enchilada casserole, Spanish rice, charro beans, banana pudding, and fruit. 10 of the 22 patients served received the main meal and the remainder received an alternate meal. The alternate meal consisted of the following: Roast turkey, candied yams, smothered squash, and a roll.

Observation on 02/02/16 at 12:15 p.m. of Patient #1 during lunch meal revealed he was served roasted turkey, candied yams, smothered squash, a roll, and grapes. Patient #1 was observed eating banana pudding after consuming all of the food on his tray. There was no staff present monitoring the patients during lunch time.

In an interview on 02/01/16 at 11:50 a.m., S6MHT indicated that he was responsible for the preparing and distribution of the patients' meals after they were delivered to the hospital. S6MHT indicated that all patients were served a regular diet. S6MHT indicated that the difference between the regular diet and the "diabetic diet" served on 02/01/16 was as follows: "A regular diet consists of 2 pieces of fried chicken, 2 servings of fried okra and a Diabetic diet is one piece of fried chicken and a small serving of fried okra."

In an interview on 02/02/16 at 9:00 a.m., S2DON indicated diabetic diets consisted of regular portions, no concentrated sweets, omission of whole milk, and addition of fresh fruits and juices. He further indicated the above referenced changes were the equivalent of a 1800 Calorie ADA Diabetic diet. S2DON provided no explanation for the other therapeutic diets.

Based on observation and interview, the hospital failed to maintain the condition of the physical plant and the overall hospital environment in a manner that the safety and well-being of patients was assured.

Findings:

Observation of the hospital's physical environment on 2/3/16 between 9:15 a.m. and 10:00 a.m. revealed the following:
a) Air conditioning units missing front casings with broken frames in patient rooms 5, 7, 8 and 9;
b) Broken floor tiles in patient rooms 5 and 9 and in the floor of the shower in the 2nd patient shower room;
c) Metal bed frames covered with a thick layer of dust in patient rooms 9, 10, 11 and 12;
d) Cracked, peeling paint above the shower in the 2nd patient shower room;
e) Rusted shower head in 2nd patient shower room;
f) Spider webs beneath the air conditioning unit, extending to the floor, in patient room 17;
g) Plastic light fixture cover cracked and noted to be loose in patient room 19;
h) Loose latch plates located on the room entry door and door facing of patient room 10.


In an interview on 2/3/16 at 10:15 a.m. with S2DON, he verified the above referenced environmental findings. S2DON agreed the above referenced environmental findings needed to be repaired/addressed.

Based on record review and interview, the hospital failed to ensure the infection control officer was qualified as evidenced by no education, training, experience, or certification in infection control.

Findings:

Review of the personnel record for S4RN revealed she had no documented evidence of training or certification in infection control.

In an interview on 2/2/16 at 9:00 a.m. with S4RN, she said she was the infection control officer at the hospital. S4RN said she did not have any specialized training for being an infection control officer and had not done any online training in infection control. S4RN said she was the infection control officer for approximately two years and had no previous experience as an infection control officer.

Based upon observations and interviews, the hospital failed to ensure a system was in place to monitor: 1) hospital furnishings to ensure the surfaces could be adequately cleaned and 2) the showers were cleaned between patient use. Findings:

1) Hospital furnishings were maintained to ensure the surfaces could be adequately cleaned.

Observations on 02/02/16 at 10:15 a.m. of the day rooms revealed the seats in the couches had numerous tears with the foam showing. The chairs had tears in the arms, backs, and seats with material showing.

Observations on 2/3/16 at 9:30 a.m. with S2DON revealed the mattresses in rooms #3, #5, #11, #12 and #16 had torn upholstery.

In an interview on 2/3/16 at 10:35 a.m. with S4RN (infection control officer), she verified if upholstery was ripped on the furniture it could not be adequately disinfected between patients.

2) The showers were cleaned between patient use.

Interviews with 4 random patients in the psychiatric unit day room on 02/02/16 at 11:00 a.m. revealed the showers were not cleaned between patient use. One random patient stated that on the weekends there were no housekeeping employees to clean the hospital.

Interview with S2DON on 02/03/16 at 10:00 a.m. confirmed housekeepers were not available on the weekends and the Mental Health Technicians were responsible for cleaning the showers between patient use. Further interview with S2DON revealed during the week the housekeeping staff cleaned the showers between patient use.

Interview with S12Housekeeper on 02/03/16 at 10:05 a.m. revealed when asked if she cleaned the showers between each patient she replied, "Yes if I see them come out of the shower." When asked if she did not see the patient come out if the shower would it be cleaned and she replied, "No."

In an interview with S4RN on 2/3/16 at 10:30 a.m., she revealed the showers should have been cleaned between patients.



30364

Based on record reviews and interview, the hospital failed to ensure each patient was counseled to prepare them for post-hospital care as evidenced by failure to provide a clear indication of changes from the patient's preadmission medications to medications the patient should be taking at discharge 3 (#8, #9, and #10) of 5 (#1,#8, #9, #10, and #11) patient records reviewed for discharge planning from a total sample of 10 patients.
Findings:

Review of the hospital policy titled "Discharge Planning", presented as a current policy by S11Social Services, revealed no documented evidence that the policy addressed that there had to be a clear indication of changes between the preadmission medications and those prescribed at discharge and that the patient and/or caregiver had to be educated on the specific changes.

Review of the medical records of Patients #8, #9, and #10 revealed there wasn't a clear indication of changes from the patient's preadmission medications to medications the patient should be taking at discharge. Further review revealed no documented evidence that the patient or caregiver was educated on the changes from the preadmission medications to those prescribed at discharge.

Based on record review and interview, the hospital failed to ensure a physician was appointed as the director of the hospital's respiratory care services. This deficient practice was evidenced by failure of the hospital's governing body to appoint a physician to serve as director of the hospital's respiratory care services.

Findings:


Review of the Hospital's organizational chart revealed no documented evidence of an appointed physician to serve as the medical director of the hospital's respiratory care services.

Review of the hospital's Governing Body meeting minutes and Medical Executive Committee meeting minutes for 2013-2015 revealed no documented evidence that S16MedicalDirector had been appointed to serve as the medical director of the hospital's respiratory care services. Further review revealed no documented evidence the governing body had appointed any physician to serve as medical director of the hospital's respiratory care services.

Review of S16MedicalDirector's credentialing file revealed no documented evidence of the hospital's governing body appointing S16MedicalDirector as director of the hospital's respiratory care services.

In an interview on 2/2/16 at 9:45 a.m. with S1Administrator, she indicated the hospital ' s S16Medical Director was the director of all services, including director of the hospital's respiratory care services.

In an interview on 2/2/16 at 10:00 a.m. with S5MD he indicated he attended medical staff meetings. S5MD further indicated, to his knowledge, the hospital had not appointed a physician S16MedicalDirector or any other physician to serve as director of the hospital's respiratory care services.