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Based on records reviewed and interviews the Hospital failed to meet the needs of the patients according to acceptable Standards of Care for respiratory services. See the publications from the National Association for Medical Direction of Respiratory Care, dated 2006 and the American Association for Respiratory Care (AARC) Position Statement titled Best Practices in Respiratory Care Productivity and Staffing, November 8, 2012.
Findings included:

The Hospital failed to appoint a physician Director for the Respiratory Care Services as required.
See A-1153

The Hospital failed to furnish appropriate numbers of qualified respiratory personnel for the delivery of respiratory services.
See A-1152

Based on records reviewed and interview a patient with a court appointed guardian was allowed to sign his/her informed consent for dialysis.

The Surveyor reviewed Patient #1's medical record on 3/23/17. Patient #1 had a court appointed guardian in place. Patient #1 had signed the informed consent for hemodialysis treatments with the treating physician.

The Director of Nursing was interviewed at 3:15 P.M. on 3/23/17. The Director of Nursing said that the hemodialysis treatment was conducted by contract staff who needed to be certain the informed consent was correctly signed.

Based on review of the Director of Quality Management position description and interviews, the Hospital failed to provide adequate resources to ensure operations in the Quality Department.

The Surveyor reviewed the position description for the Director of Quality Management dated 2/7/17. The position description indicated that the Director of Quality Management was responsible for the performance improvement activities including risk management, complaints and grievances, regulatory readiness, investigations and root cause analysis of serious events. The position description also indicated that the Director of Quality Management performed the functions of the infection control practitioner for surveillance, reporting, coordinating infection control committee meetings, environmental rounds and the hazardous material management program. Additionally, the position description indicated that the Director of Quality Management participated in hospital orientation and staff in-services for infection control and quality improvement topics.

The Surveyor interviewed the Director of Quality Management and the Chief Executive Officer (CEO) #2 at 10:30 A.M. on 3/28/17. The Director of Quality Management verified that the Hospital no longer had the positions of Infection Control or Staff Education. The Director of Quality Management said these roles had been incorporated into the Quality Directors role. The Director of Quality Management said she was also assigned the Employee Health duties.

CEO #2 said that the Hospital had been purchased by a new company and a number of positions were consolidated at that time.

CEO #2 said that since the change in ownership, the Hospital no longer had an electronic medical record although the Hospital would sometime in the future. Without an electronic medical record all surveillance activities for infection control and the quality indicators would be done manually a very time consuming activity.

Based on records reviewed and interviews the Hospital failed to appoint a Physician Director for the Respiratory Care Services.
Findings included:

According to the National Association for Medical Direction of Respiratory Care, dated 2006, the Medical Director is responsible:
a. For the delivery of Respiratory Care Services with 24-hour availability
b. To Interact directly with the respiratory care personnel promoting problem-solving and guidance.
c. To monitors and prevents mis-utilization of respiratory therapies
d. As the expert with knowledge and training in the use of respiratory care equipment
e. To oversee the protocols for endotracheal tube and tracheostomy tube management and intubation, chest physiotherapy, ventilator management, aerosol and inhaled bronchodilator therapy
f. To participates in development, evaluation and introduction of new respiratory services, equipment, protocols and procedures, and also monitors current respiratory services for their continued medical usefulness.
g. To review physician performance in prescribing respiratory therapies
h. To Provide consultation to physicians with respect to availability and appropriateness of requested respiratory care and diagnostic services
i. To shares responsibility with and provides medical expertise to the Administrative/Technical Director of the Respiratory Care Service in matters regarding: Equipment; Personnel; Supplies; Budget; Space; Infection Control; Policies and Procedures; Safety; Preventative Maintenance; Medical Gas Systems; Record Keeping; Fiscal and Regulatory Agencies
j. For seeing that the Respiratory Care Service is in compliance with Federal, State and JCAHO Regulations.

The Surveyor reviewed the Hospital's website scope of services which indicated the care of complex respiratory and ventilator weaning patients.

The Surveyor interviewed the Director of Nursing at 8:50 A.M. on 3/23/17. The Director of Nursing said that she was the person that the Respiratory Department now reported to since some departmental changes some months before.

The Surveyor re-interviewed the Director of Nursing at 12:30 P.M. on 3/27/17. The Director of Nursing said that the position of Director of Respiratory Care had been consolidated into her position. The Director of Nursing said she was unaware of a Physician Director for the Respiratory Service.

Chief Executive Officer (CEO) #2 was interviewed on at 10:30 A.M. on 3/28/17. CEO #2 said the Medical Director of the Hospital was perhaps the Director of the Respiratory Care Service.

The Surveyor reviewed the credential files for the Medical Director who was a surgeon and internal medicine physician. The credential file indicated the Medical Director had requested privileges for ventilator and tracheotomy management specifying with help from the Pulmonary Specialist.

Based on observations, records reviewed and interviews the Hospital failed to provide adequate qualified respiratory staff to consistently fulfill the role of the Respiratory Therapist.
Findings included:

According to the American Association for Respiratory Care (AARC) Position Statement titled Best Practices in Respiratory Care Productivity and Staffing, November 8, 2012, indicated:
a. Understaffing puts at risk the welfare and safety of patients
b. When constructing a staffing system, the need for "core or minimal staffing" should be determined This means that some staff is always available to immediately respond to an emergency situation.
c. Staffing adjustments, driven by any workload estimation system or benchmarking analysis, must include a mechanism to assess the effects of staffing on patient outcomes.
d. Metrics used for staffing must capture the full range of activities required of respiratory therapists in order to ensure consistent, safe, cost-effective and high quality care.
e. Understaffing respiratory care services places patients at risk for unsafe incidents, missed treatments and delays in medication delivery, as well as increases the liability risk for the hospital

The Surveyor interviewed the Director of Nursing at 8:50 A.M. on 3/23/17. The Director of Nursing said that she was the person that the Respiratory Department reported to since some departmental changes some months before. The Director of Nursing said there had been some readjustments to the staffing levels since the transition between prior and current owners. The Director of Nursing said that the staffing was now two Respiratory Therapists on the 7:00 A.M. to 7:00 P.M. and one on the 7:00 P.M. to 7:00 A.M. shift. The Director of Nursing said there was a position opening for a lead Respiratory Therapist that was currently posted, but the final staffing numbers would remain the same when that position was filled. The Director of Nursing said that, while the nursing staff numbers would be adjusted according to the census and acuity needs, there were no provisions for adding additional respiratory staffing; however, the Director of Nursing said if there were more than ten ventilated patients there would be a conversation related to staffing of the Respiratory Therapy Department. The Director of Nursing said there was no agency use in the Respiratory Department. The Director of Nursing said that occasionally there was only one Respiratory Therapist on the 7:00 A.M. to 7:00 P.M. shift but normally the were two Respiratory Therapists on duty. The Director of Nursing said that many patients are weaning during the day but return to the ventilators overnight to rest.

The Surveyor reviewed the Emergency Airway Box Log for West Two and Central One during the morning unit tours on 3/23/17. The Emergency Airway Box Log for West Two indicated it had not been checked since 12/29/16. The Emergency Airway Box Log for Central One indicated it had not been checked since 1/9/17.

The Director of Nursing said the Emergency Airway Box should have been checked by the Respiratory Therapist weekly during those dates.

The Surveyor reviewed the 2012 American Association for Respiratory Care (AARC) Position Paper regarding Respiratory Care Productivity and Staffing. The Position Paper indicated that when constructing a staffing system, the need for "core staffing" or "minimal staffing" should be determined. This means that some staff is always available to respond to emergency situations.

Respiratory Therapist # 1 said she had worked on a number of shifts when there was only one therapist available. Respiratory Therapist #1 said when there was a code blue or other emergency there was no respiratory coverage for the other patients. Respiratory Therapist #1 said some of the Respiratory staff had picked up excessive numbers of hours so that their colleagues were not left alone.

Respiratory Therapist #2 said she believed patients weaning schedules had been delayed because of lack of staff.

Registered Nurse (RN#1) said she had worked shifts on the 7:00 P.M. to 7:00 A.M. shift. RN#1 said she was able to do a number of tasks for the patient on a ventilator like reconnecting and suctioning; however, RN#1 said she was not qualified to manage the patient on a ventilator. RN#1 said the Nursing Supervisor covered for the Respiratory Therapists' breaks and mealtime but sometimes the Nursing Supervisor had a patient assignment themselves.

Registered Nurse (RN#4) said she had worked shifts on the 7:00 P.M. to 7:00 A.M. shift. RN#4 said the Respiratory Therapy support was not good. RN #4 said she was able to suction and assess her ventilated patient but if you needed Respiratory Therapy and they were tied up with another patient that you would have to wait for them to arrive. RN #4 said that made her feel unsafe even though there had been no bad outcomes thus far.

The Surveyor reviewed the Respiratory Therapy patient assignment on 3/28/17. The assignment indicated there were five patients on ventilators with four patients actively weaning. The assignment indicated twenty patients were on the assignment list requiring some measure of respiratory services. Respiratory Therapist #3 said she would be working until 3:00 P.M. that day because she had volunteered to do extra hours to make the second therapist on the day shift.

Respiratory Therapist #3 said that they were required to perform ventilator checks every four hours around the clock. Respiratory Therapist #3 said a ventilator check took from 15 to 30 minutes to complete depending on the patient's needs.

The Surveyor interviewed the Staffing Coordinator at 3:15 P.M. on 3/27/17. The Staffing Coordinator said she had not been successful in obtaining an agency that would provide them with additional Respiratory Therapists. The Staffing Coordinator said there was an open position that was posted some 3 months before but they had not received qualified applicants.

The Staffing Coordinator provided the Surveyor with the Respiratory schedule for the week of 3/17 through 3/24/17. The schedule indicated that on 3/17, 3/18, 3/19, 3/21 and 3/24/17 there was only one Respiratory Therapist on duty for the 7:00 A.M. to 7:00 P.M. shift.

The Staffing Coordinator provided the Surveyor with the timecard documentation for the prior two pay periods. The timecard documentation indicated a Respiratory Therapist had worked 133 hours in a two week pay period and 99 hours in another.

The Surveyor reviewed the four patients in the survey sample (Pt #6, #7, #8 and #9) whose treatment goal was to be weaned from the ventilator.

For Patient #6, no Interdisciplinary Care Conferences had been conducted since his/her recent admission.

For Patient #7, a total of four Interdisciplinary Care Conferences had been conducted since admission with multiple disciplines in attendance (i.e. case management, nursing, nutrition, pharmacy and rehabilitation) however, none were attended by a Respiratory Therapy representative.

For Patient #8, a total of two Interdisciplinary Care Conferences had been conducted since admission with multiple disciplines in attendance (i.e. case management, nursing, nutrition, pharmacy and rehabilitation); however, none were attended by a Respiratory Therapy representative.

For Patient #9, a total of four Interdisciplinary Care Conferences had been conducted since admission with multiple disciplines in attendance (i.e. case management, nursing, nutrition, pharmacy and rehabilitation); however, none were attended by a Respiratory Therapy representative.