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Based on a review of facility documents, medical records (MR), and staff interview (EMP), it was determined that the governing body failed to ensure that the facility's respiratory care shared service complied with the applicable conditions of participation and standards for respiratory therapy (A-0043) and failure to ensure that the shared service of respiratory therapy was provided in a safe and effective manner and met the needs of its patients (A-0084).

On July 24, 2022, it was identified that there was no Respiratory Therapist at the facility for an unknown period of time.


Cross Reference

482.12 (e)
482.12(e)(1)
482.12(f)(2)

Based on a review of facility documents and staff interview (EMP), it was determined that the governing body failed to ensure that the facility's respiratory care shared service complied with the applicable conditions of participation and standards for the respiratory therapy.

Findings include:

On September 14, 2022, a review of the facility's ADMINISTRATION- Scope of Service, dated 10/21 stated, "l. Responsible for the organization compliance with laws, regulations .....(m) President, through the management and administrative staff, provides for the implementation of organized management and administrative functions throughout the organization, including the establishment of clear lines of responsibility and accountability within departments and between department heads and administrative staff ...."

On September 14, 2022, a review of the facility's RESPIRATORY CARE- Scope of Services, dated 03/22 stated, "I. Scope: Respiratory Care provides patient care services 24 hours a day and 7 days a week to patients of all ages."

On September 14, 2022, a review of the facility's Manager of Respiratory Care Position Description, dated 3/3/2022) stated, "Essential Functions: 1. Major Duties and Responsibilities b. Provides leadership to address and resolve conflicts and problems and supports a process of frontline problem solving to enhance quality, safety, customer satisfaction and waste reduction."

On September 15, 2022, a review of the facility's Position Description for the Vice President of Operations/President WHS- Greene, dated 7/1/2016, stated, "2. Safety and Compliance: a. ... complies with all external regulatory and accrediting bodies while ensuring safety of patients/families, visitors and staff."

On September 15, 2022, a review the facility's Core VP Operations/President WHS Greene Skills and Responsibilities, (not dated), states, "2. Oversees ...staffing, smooth operations and compliance with organizational policies, practices and procedures. 6. Directs activities of subordinates according to priorities and maintains competent employees and adequate staffing levels."

During interviews on September 14, 2022, 10:50AM and 12:58PM, EMP1, EMP2, EMP3, and EMP5, confirmed that the hospital was without the services of respiratory therapy for an unknown period on July 24, 2022.

During an interview on September 14, 2022, at 12:05PM, EMP3 stated that he informed EMP4 that, "We need to have coverage 24 hours per day."

During an interview on September 14, 2022, at 12:05PM, EMP4 confirmed the directive given from the EMP3 that the facility needed to have respiratory therapy coverage 24 hours per day.

During an interview on September 15, 2022, between 10:00AM -11:00AM, EMP4 and EMP8 revealed that on July 24, 2022, the hospital was without a respiratory therapist for an unknown period. However, EMP4 estimated the time to be approximately 1.5 hours.

During an interview on September 15, 2022, EMP8 indicated that there were numerous discussions surrounding the event on July 24, 2022, but no changes to systems or processes had been made to prevent recurrence.

Based on a review of facility documents, medical records (MR) and staff interviews (EMP), it was determined that the governing body failed to ensure that respiratory care services were provided in a safe and effective manner.

Findings include:

A review of the RESPIRATORY Care- Scope of Service (last Reviewed/Revised 3/2022), revealed that the Department is staffed with a total of six (6) full time employees and two (2) casual staff members. Department reports directly to the President Washington Health System Greene with the support of the Manager of Respiratory Care at WHS.

A review of the department schedule on September 15, 2022, reveal that no respiratory therapist (RT) were scheduled on 7/24/2022, for the 7:00AM to 7:00PM shift.

On July 24, 2022, a review of MR1 revealed that the patient arrived intubated and in cardiac arrest with no respiratory therapist in the facility. Further review revealed that the patient was manually ventilated from 12:32PM to 12:58PM, when the physician determined no further efforts at resuscitation would occur.

On September 14, 2022, at 9:55AM, EMP6 stated, "RNs do not do anything with vents; therefore, there will be no documentation of training [for registered nurses]."

Interviews with EMP1, EMP2, EMP3, and EMP5, conducted on September 14, 2022, between 10:50AM and 12:58PM, revealed that the hospital was without the services of respiratory therapy for an unknown period on July 24, 2022.

During an interview on September 14, 2022, at 11:30AM, EMP4 stated that the staffing pattern is one RT from 7:00AM to 7:00PM and one RT from 7:00PM to 7:00AM.

On September 14, 2022, at 11:45M, EMP4 stated that the respiratory therapy department was short a full-time RT and had another RT on leave. As a result, Respiratory Therapy Director EMP4 provided the RT coverage at the facility on July 24, 2022. EMP4 further explained that he was needed at another facility and therefore left the building, despite knowingly leaving the building without RT coverage. EMP4 explained that he needed to get "eyes on" and "boots on the ground" to assess the situation at the other facility. When asked to explain the department's contingency plan if the emergency department needed a ventilator and no RT were in the building, EMP4 stated the ED staff could "hit the on/off button" on the ventilator.

On September 14, 2022, at 1:10PM, EMP7 stated that the emergency room staff called EMP4 and stated, "... we had a code coming in." EMP4 told EMP7 that he would return to the facility "as soon as possible.......another RN stated she knew how to set up the ventilator." Additionally, EMP7 stated that EMP4 returned to the facility at "the end of the code."

On September 15, 2022, during an interview at 10:00AM, EMP4 estimated that the time the facility was without a respiratory therapist was "approximately" 1.5 hours but could not be certain.

On September 15, 2022, at approximately 11:00AM, EMP8 confirmed that the hospital was left without coverage for an unknown period on July 24, 2022.

Based on a review of facility documentation and staff interview (EMP), it was determined that the facilty failed to meet the needs of the patients in accordance with respiratory care services acceptable standards of practice as evident by failure to have a respiratory therapist on duty at the facility (A-1154) and failure to have qualified personnel (A-1160).

On July 24, 2022, it was identified that there was no Respiratory Therapist at the facility for an unknown amount of time.

Cross Reference
482.57 - Respiratory Care
482.57 - (a)(2) Adequate Respiratory Care Staffing

Based on a review of facility documentation, and staff interview (EMP), it was determined that the facility failed to ensure a respiratory therapist was available at all times.


Findings include:


On September 14, 2022, a review of "RESPIRATORY CARE- Scope of Services" (Last Reviewed/Revised, dated 03/22) revealed, "I. Scope: Respiratory Care provides patient care services 24 hours a day and 7 days a week to patients of all ages."


On September 14, 2022, at 9:30 AM, a review of the scope of practices for Registered Nurses (RN) and Respiratory Therapists (RTs) revealed that only the RT scope of practice included ventilator management. Additionally, the RN scope of practice did not include ventilator management or the drawing of arterial blood gases. These findings were confirmed by EMP6 at the time of the review.



A review of the staffing schedule for July 24, 2022, revealed that there was no RT scheduled to work the 7:00AM to 7:00PM shift and therefore the shift was covered by the Respiratory Therapy Director EMP4.


During an interview on September 14, 2022, at 10:52 AM, EMP2 described the following: "When I came to work on Monday July 25th, I was informed by my nurse that there was a period of time on Sunday [July 24, 2022] that there was no Respiratory Therapist available in the building. My nurse was concerned because he left and during that time a cardiac arrest came into the Emergency Department. The patient was having CPR performed and breathing was being assisted by ambu bag." Additionally, EMP2 was asked if the Emergency Department RNs could place the patient on a ventilator if needed and EMP2's response was "no." Upon further interview EMP2 revealed, "The Respiratory Therapists are the only ones other than the doctors who can draw arterial blood gases (ABGs)."


During an interview on September 14, 2022, at 12:05PM, Chief Executive Officer EMP3 stated, "We need to have [RT] coverage 24 hours per day."

Based on a review of facility documents and staff interviews (EMP), it was determined that the facility failed to follow facility policies regarding the administration of respiratory care services.


Findings include:


On September 14, 2022, a review of Respiratory Care- Scope of Services (Last Reviewed/Revised 03/22) states, "Respiratory Care provides patient care services 24 a day and 7 days a week to patients of all ages."


On September 14, 2022, Respiratory Care Manual- Mechanical Ventilation Guidelines (Last Reviewed: 01/2022) was reviewed.


Interviews conducted on September 14, 2022, with EMP1, EMP2, EMP3, and EMP5, between 10:50AM and 12:58PM, confirmed that the hospital was without the services of respiratory therapy for an unknown period on July 24, 2022.



On September 14, 2022, at 11:30AM, EMP4 stated that Respiratory Therapy Department's contingency plan in the absence of an RT on duty was that the nurse or physician would have to "only hit the on/off button [on the ventilator]."



On September 14, 2022, at 12:35PM, EMP5 stated that the situation made EMP5 very uncomfortable. During the interview EMP5 confirmed that nurses in the facility did not have training to place patients on the ventilator.


During an interview on September 14, 2022, EMP7 stated that the emergency room physicians were responsible for prescribing ventilator settings. When asked if the emergency department physicians would be comfortable placing the patient on a ventilator, EMP7 replied, "They would have no other choice."


On September 15, 2022, during an interview at 10:00AM, EMP4 estimated that time EMP4 was out of the facility and with no respiratory therapist on duty was approximately 1.5 hours.


On September 15, 2022, at approximately 11:00AM, EMP8 confirmed that the hospital was left without coverage for an unknown period on July 24, 2022.