HospitalInspections.org

Based on observation, record review and interview, the facility failed to provide adequate numbers of respiratory therapists to meet the needs of the respiratory patients (A1154), and failed to ensure respiratory patients were assessed and monitored timely in accordance with facility policy. The cumulative affect of this systemic process resulted in the inability of the facility to assess and monitor respiratory patients in accordance with facility policy and patients' needs.

Based on staff interviews and record reviews, the facility failed to ensure all staff qualified to participate in rapid responses were knowledgeable about the rapid response participants and rapid response records and failed to specify all team members who participated or who were required to participate. This affected two (Patient #6 and #10) of five patients who required a rapid response intervention and could potentially affect all patients in the facility. A combined census was 52 patients for both campuses.

Findings include:

During this survey between 09/07/17 and 09/12/17, various staff were questioned as to the members of the rapid response team. A review of all Rapid Response Team Records were conducted for August and September 2017.

Interviews conducted with different disciplines (Registered Nurses, Respiratory Therapist, and Administration) revealed different answers from staff on who composed the Rapid Response Team and how assignments were made for assigning team members each day.

The interviews were as follows:

a) Registered Respiratory Therapists are always a part of Rapid Response Team per interview with Staff E (Respiratory Therapy Manager) on 09/07/17 at 11:33 AM.

b) During tour of the Medically Complex Unit on 09/07/17 at 10:00 AM, a Respiratory Therapist (RT) stated all RTs respond to Code Blue and Rapid Responses, including the RT manager, and if there are enough staff present the extra staff will be sent back to their patient care assignment.

c) On 09/12/17 at 2:47 PM an interview was conducted with Staff Z (RT). Staff Z stated that the RT always responds to the Rapid Response, but may not always be needed after arrival, depending upon the nature of the call.

d) On 09/08/17 at 9:05 AM and interview was conducted with Staff B, at which time Staff D was present. The interview was conducted in regard to who the team members of the Rapid Response team (RRT) were, and about the process and documentation of the team members on the RRT record. Staff B stated all charge nurses (one per shift) have taken the online RRT class, and stated the facility does not have a set required team. Staff B stated there is a leader (charge nurse) and assistant Registered Nurse, and the house physician. However, on night shift beginning at 8:15 PM, the house physician hands over the care to Telemedicine team who are critical care staff that are located off-site.

Staff B explained that Telemedicine team is located off-site in a "bunker" and communicates and assesses the patients' status electronically. Staff B explained when Telemedicine is used, a portable machine is brought into the patient's room and hooked up to the patient. The screen will show one staff member from the bunker which is comprised of Nurse Practitioner, Physician, and critical care Registered Nurses. Staff B confirmed the Rapid Response Team records only list the person who communicates from the bunker (Nurse Practitioner and not a physician).

This finding was verified per review of the August 2017 Rapid Response Team records that occurred after 7:00 PM.

Staff B stated, that during the day shift, staff who respond to rapid responses are nurses who are ACLS certified and only a charge nurse and a back-up Registered Nurse (RN) responds initially, and that additional staff are designated as a runner or helper. Staff B stated there was no policy for assignment of the RRT and Respiratory Therapists don't have to be part of the Rapid Response initially, only if needed. Staff B stated the Rapid Response is led by the Charge Nurse unless the physician is present, and then it is led by that discipline. Staff B stated the assignment sheet lists the nurses' names for the Rapid Responses and identifies who the RT is on duty but confirmed the RT is not assigned to respond during a Rapid Response.

e) An interview with Staff D (Staff C also present) on 09/08/17 at 2:50 PM revealed the following protocol is the one the hospital follows for the Rapid Response Team:

"Rapid Response Team (RRT) Program Information, Early Recognition and Intervention Initiative"
"Expectations:
1. It is an expectation that our hospitals have fully functional Rapid Response Teams in place that are led by our staff/physicians.
2. The CNO will select RNs and the Respiratory Manager will select RTs based on the selection criteria below.
3. A minimum of 1 RN and 1 RT will be assigned every shift as a RRT Responder.
4. RRT Responders must complete the requirements to function in this capacity."

f) On 09/08/17 at 3:45 PM a contract with Cleveland Clinic Foundation (CCF) for Remote Monitoring Services (Telemedicine) of patients was provided by Staff A. The contract specifies "CCF utilizes an audio-visual electronic device as described in Exhibit B ("Equipment") to observe remotely, via the Internet, Regency's patients and assist Regency in assessing such patient's medical care needs."
" The expectation is that a CCF Personnel (mid-level provider or, critical care nurse), will initiate a timely response and the physician will respond to Regency in less than 10 minutes of receiving Regency's request for service."
"CCF and Regency will keep a call log with at least the following data: Patient name, time of the call, reason for the call, and intervention (by category such as: monitoring, hemodynamic, respiratory, metabolic support, etc.)."

g) On 09/11/17 at 9:38 AM an interview was conducted with Staff A, in the presence of Staff B, C, and D. Staff A stated a physician is present in the bunker along with two nurse practitioners (NP), four Registered Nurses (RN), and two Physicians, and is located offsite in a nearby city and they monitor through the contractual agreement for Telemedicine.

Staff A also confirmed the contract for Telemedicine physician should notify the facility within 10 minutes of the response. Staff A stated the House Officer (in-house physician) works concurrently with the eHospital; however, the eHospital serves as the primary physician and is responsible for managing the episode and writing orders.

On 09/11/17 at 4:00 PM, Staff D presented the Telemedicine Bunker staff list for August and September 2017 and the facility log for Telemedicine. The logs and rapid response team records for August 2017 lacked physician participation when Telemedicine was involved. When asked if the facility had any additional documentation of who was present for the Rapid Response Team Records for August and September 2017, Staff D responded that it would either be on the paper medical record, in the electronic medical record or on the Rapid Response Record Forms. Facility staff were only able to provide a Remote Physician Consult Log for Telemedicine which failed to list physicians who may been present during Rapid Responses.

h) A Rapid Response was called for Patient #6 on 08/13/17 at 0152 for tachycardia HR 102-170s. Responded were Charge RN and another RN and eHospital Nurse Practitioner. There was no documentation on the RRT record of physician participation with the exception of notification of a physician at 11:45 PM, however, there was no date listed.

i) On 08/12/17 at 7:39 PM a Rapid Response was called for Patient #10 for respiratory distress. The rapid response team critique form lacked participation of a Respiratory Therapist during the Rapid Response.

Based on record review and staff interview, the facility failed to ensure patients were evaluated upon return from an acute care facility. This affected one of one medical record reviewed who returned from an acute care facility (Patient #1). A total of 12 medical records were reviewed. The facility census was 52 for both campuses.

Findings include:

Review of the medical record for Patient #1 revealed an admission date of 07/13/17. The patient's diagnosis was acute respiratory failure. The medical record contained documentation that the patient was on Bipap at night and vapotherm (heated high flow oxygen per nasal cannula) during the day. The medical record contained documentation that a rapid response was called on 08/07/17 due to a change in mental status, garbled speech, and weakness during hemodialysis. The patient was sent to the emergency room for evaluation. The medical record contained a notation in the respiratory therapy assessment on 08/08/17 at 4:46 PM that the patient was back from the acute care facility with no distress. The physician progress note dated 08/08/17 documented that the patient had been sent out the previous day for acute mental status and suspected stroke with an unremarkable evaluation and returned to the facility. The nursing documentation included a shift assessment at 8:00 PM on 08/08/17 but lacked documentation of the patient being sent out or returning from an acute care facility. The facility log noted the patient returned from the emergency room on 08/08/17 at 4:17 PM.

This finding was verified on 09/11/17 at 10:00 AM by Staff B.

Based on interviews and record reviews, the facility failed to provide adequate numbers of respiratory therapists to meet the needs of the respiratory patients. This affected 6 of 8 sampled patients (Patients #1, #2, #6, #9, #3 and #5) who had every three hour monitoring and assessment of respiratory needs. This could potentially affect all respiratory patients in the facility with the same needs. The total census was 52 patients at both campuses.

Findings include:

Review of the facility's policy titled "Assessment & Reassessment by Respiratory Therapy (RT-01)" was reviewed and revealed (on page 2) that "patients with artificial airways, non-invasive ventilation, or requiring heated high flow oxygen are reassessed at least every three (3) hours, while those receiving less extensive therapy will be assessed each shift. Reassessment includes but is not limited to: HR (heart rate), RR (respiratory rate), BS (breath sounds), SpO2, oxygen/vent settings, work of breathing, secretion clearance, airway patency, patient tolerance, adverse reactions, etc."

Review of the facility's policy titled "Vent Management (RT-10)" was reviewed and revealed under the heading Continuation of Therapy (page 2) that "ventilator checks and patient assessments should be completed Q3 hours." The assessment "should include" but was not limited to "time of assessment; current settings and alarms; tube position; HR, RR, breath sounds; sputum amount, color, consistency; head of bed elevation >30 degrees; weaning tolerance and progression."

Tour of the facility's High Observation Unit was conducted on 09/07/17 at 9:25 AM with Staff E, Respiratory Therapy Manager. Three of the eight patients (Rooms 102, 105 and 107) on the unit were currently on a ventilator, per observation. Staff E was asked to explain who was responsible for the daily management of the ventilator equipment and the frequency with which patient assessments were conducted. Staff E stated the ventilators were managed by the Respiratory Therapists (RT). Staff E stated those patients on a ventilator were to be assessed by a RT every three (3) hours. Staff E stated the RT was also to check the ventilator settings and suction the patient if needed.

Three patients (Rooms 103, 104 and 107) currently had a tracheostomy (trach) in place, per observation. Staff E was asked to explain who was responsible for the daily management of the tracheostomy and the frequency with which patient assessments were conducted. Staff E stated the RT was to check on these patients at least every four (4) hours. Staff E stated the RT would check the humidification bottle (s) if present, suction the patient if needed. Staff E stated trach care was performed by the RT once per shift.

1. Patient #2 was admitted to the facility on 08/03/17 with a diagnosis of Respiratory Failure. He was on a ventilator at the time of his admission per physician's order. Review of a sampling of the RT Assessments with Staff E on 09/08/17 at 9:46 AM revealed the following:

a) On 08/04/17 a RT assessment was completed at 6:30 PM then not again until 11:30 PM, five (5) hours later. There was no documented evidence why the assessment was delayed.
b) On 08/08/17 a RT assessment was completed at 7:00 AM then not again until 11:00 AM, four (4) hours later. There was no documented evidence why the assessment was delayed.
c) On 08/09/17 a RT assessment was completed at 3:04 AM then not again until 7:00 AM, approximately four (4) hours later. There was no documented evidence why the assessment was delayed.
d) On 08/10/17 a RT assessment was completed at 3:29 PM then not again until 7:16 PM, approximately 3 hours and 45 minutes later. There was no documented evidence why the assessment was delayed.
e) On 08/12/17 at 1:44 PM RT began trialing ATC (automatic tube compensation) with Patient #2 in an attempt to wean him off of mechanical ventilation. At this point Patient #2 still had an artificial airway (endotracheal tube or trach) in place. Staff E stated RT should perform an assessment of Patient #2 during the ATC trial every three (3) hours for the first 48 hours and then every four (4) hours. This was not in accordance with facility policy.

Review of a sampling of the RT Assessments while on ATC trial with Staff E revealed the following:

f) On 08/12/17 a RT assessment was completed at 6:26 PM then not again until 10:53 PM, more than four (4) hours later. The next documented RT assessment was on 08/13/17 at 10:05 AM, approximately 11 hours later. There was no documented evidence why the assessments were delayed.
g) 11:00 AM. An assessment was completed at 2:37 PM, then approximately five hours later at 7:45 PM. At this time Patient #2 had a trach mask in place and per policy every three (3) hour assessments were still required.

Staff E confirmed the above the findings related to Patient #2 at the time of the record review.

2. Patient #3 was admitted to the facility on 07/31/17 with a diagnosis of Respiratory Failure. He was on a ventilator at the time of his admission per physician's order. Review of a sampling of the RT Assessments with Staff E on 09/08/17 at 11:30 AM revealed the following:

a) On 08/01/17 a RT assessment was completed at 2:43 PM then not again until 7:27 PM, approximately 4 hours and 45 minutes later. There was no documented evidence why the assessment was delayed.
b) On 08/01/17 a RT assessment was completed at 11:00 AM and then not again until 3:00 PM, four hours later. There was no documented evidence of why the assessment was delayed.
c) On 08/09/17 a RT assessment was completed at 1:07 AM then not again until 4:57 AM, approximately four hours later. An assessment was done at 7:00 AM and then again when the vent was liberated at 12:00 PM, five hours later. There was no documented evidence why the assessments were delayed.
d) With a trach mask in place, RT assessments were completed on 08/12/17 at 10:41 PM then not again until 3:00 AM on 08/13/17, more than four hours later. The next RT assessments were at 7:00 AM and then 11:00 AM, each four hours apart. There was no documented evidence why the assessments were delayed.
F) Patient #3 was placed back on a vent on 08/13/17 at 5:20 PM. Review of the RT assessments revealed one was completed on 08/14/17 at 3:00 PM and then not again until 8:26 PM, approximately five and a half hours later. There was no documented evidence why the assessment was delayed.

Staff E confirmed the above findings related to Patient #3 at the time of the record review.

3. On 09/11/17 Patient #6's medical record was reviewed and confirmed with Staff E. The medical record review revealed Patient #6 was admitted on 07/27/17 with diagnoses of Acute and Chronic Respiratory Failure with Hypoxia, Congestive heart failure, hypertension, severe Chronic Obstructive Pulmonary Disease with respiratory failure.

During the patient's hospital stay, the patient's physician orders were for continuous oxygen, high flow mask, and Bipap machine. On 08/11/17 the physician ordered high flow oxygen with humidity and face tent with a target saturation (oxygen) equal to 88%.

Interdisciplinary (IDT) and discharge and Barrier Update weekly note on 08/02/17 contained the following documentation: the patient was non-compliant with wearing Bipap, on/off all the time and desats quickly. Takes a while to come back up in sats (oxygen saturation level). IDT present except physician. Explained cannot eat with Bipap on. Desats quickly. Up most of night, refusing Bipap per assessment.

The 08/0/9/17 IDT note had documentation the patient was a possible Skilled Nursing unit placement from this hospital and oxygen dependence increased from 9 liters/minute to 15 liters/minute this past week, and patient was non-compliant with Bipap.

The Respiratory Therapy (RT) assessment on 08/14/17 at 7:00 AM had documentation as follows: Ambu (bag)with mask at bedside, continuous pulse ox on, pulse ox alarms audible and functioning, Bipap plugged into emergency outlet, Oxygen Saturation level 90%.

The medical record review revealed a lack of every three hour monitoring and assessments by the Registered Respiratory Therapist (RRT) as follows:

a) On 08/13/17 between 7:00 AM and 11:00 AM (4 hours), 11:00 AM and 3:00 PM (4 hours), 3:00 PM and 7:35 PM (4 hours and 35 minutes), and from 10:35 PM to 2:44 AM ( over 4 hours) on 08/14/17, and
b) On 08/14/17 between 2:44 AM and 7:00 AM (over 4 hours) and 7:00 AM and 10:37 AM (3 hours and 37 minutes) at which time the Respiratory note contained documentation the patient expired.
c) An RT note on 08/13/17 at 10:44 PM had documentation the patient was on a non-rebreather mask with high flow oxygen.
d) A Rapid Response Record review revealed on 08/13/17 at 1:52 AM the patient had tachycardia (increased heart rate between 120s-170s).

There was no documented reasons for the late assessments and monitoring by respiratory staff.

On 09/11/17 at 3:45 PM, Staff E confirmed the lack of respiratory assessments and monitoring every three hours was not done per facility policy on 08/13/17 and 08/14/17 by the RT for the Bipap and heated high flow oxygen with non-rebreather mask.

4. On 09/11/17 Patient #9's medical record was reviewed and confirmed with Staff E. Patient #9 had a date of admission of 06/20/17 and diagnoses of Acute Respiratory Failure, Aspiration Pneumonia, hypertension, dysphasia, Colon cancer, liver cancer, runs of SVT (superventricular tachycardia), and Schizoaffective disorder.

The record review revealed physicians' orders for telemetry, tube feeding, Mechanical Ventilator, Oxygen as needed, a tracheostomy (trach) tube #6 DCT (disposable cuffed trach tube), trach care every shift and as needed (prn), and RT provides oral care including suctioning.

The medical record contained information the patient had an RT High Risk Airway (HRA) Assessment on 08/02/17. The endotracheal tube physician, the charge nurse, the nurse assigned to patient, the safety huddle group had been notified of the HRA, and a sticker was placed on the head of the patient's bed.

A Rapid Response team record on 08/01/17 at 11:53 PM contained the following documentation: Respiratory Therapist, Registered Nurse (RN), Doctor in house and Remote Management (Telemedicine) RN present for respiratory distress. Pt was found in respiratory distress, RT was called to patient room due to patient's Sats (oxygen) being in the low 90's. Put patient on HFNC (high flow nasal cannula) but the Sats did not go up very good. Started bagging pt and a rapid response was called. While bagging Sats came up and changed patient went to over 100% NRB (non-rebreather mask). Patient was not able to maintain sats and house Doctor wanted to intubate. The patient was intubated by the RT on the third attempt by the RT and one attempt by the physician, the patient and placed on the ventilator. The patient was decannulated on 07/13/17 and on 08/01/17 at 7:46 PM was on 4 liters of oxygen per nasal cannula with no respiratory distress.

The RT monitoring and assessment of the patient while on the mechanical ventilator was not done every three hours per facility policy as follows:

a) On 08/02/17 between 7:00 AM and 10:30 AM (3 and 1/2 hours), from 7:35 PM-11:37 PM (over 4 hours), and from 11:37 PM and 3:13 AM (over 3 and 1/2 hours) on 08/03/17,
b) On 08/03/17 between 3:13 AM and 7:00 AM ( 3 hours and 47 minutes), from 10:00 AM-7:35 PM (9 hours and 35 minutes), from 7:35 PM-11:20 PM (3 hours and 45 minutes), between 11:20 PM and 3:00 AM (3 hours and 40 minutes) on 08/04/17,
c) On 08/04/17 between 3:00 AM and 6:55 AM (3 hours and 55 minutes), between 10:13 AM and 1:52 PM (over 3 and 1/2 hours) at which time a cpap was added per physician's order, between 3:41 PM and 7:07 PM (almost 3 and 1/2 hours) (50 % Ventimask was used when patient was extubated between 3:40 PM and 7:07 PM), between 7:07 PM and 10:23 PM. At 10:23 PM, the patient was placed on 100% NRB (non-rebreather mask) due to increased workup breathing (energy expended to inhale and exhale a breathing gas) and increased respiratory rate, and 10:23 PM on 08/04/17 and 3:35 AM on 08/05/17,
d) On 08/05/17 between 11:00 AM and 3:20 PM (over 4 hours), between 3:20 PM and 7:00 PM (3 hours and 40 minutes), between 7:00 PM and 11:00 PM (4 hours), and on 08/05/17 between 11:00 PM and 3:00 AM (4 hours) on 08/06/17, and
e) on 08/06/17 between 3:00 AM and 7:10 AM (over 4 hours), and between 7:10 AM and 10:45 AM (over 3 and 1/2 hours).

On 08/05/17 at 3:32 AM the patient's respiratory rate was elevated at 31 per minute, and pre-heart rate was 116 and breath sounds in right and left lungs were diminished with crackle sounds upon auscultation.

The patient expired at 12:13 PM on 08/06/17 while on the NRB mask. The RT note at 10:45 AM on 08/06/17 contained the following documentation: Oxygen saturation level was 94%, heart rate 111, and respirator rate 24 per minute. The patient had diminished breath sounds in the right and left lungs. The aerosol breathing medications was changed to every four hours as need for comfort.

On 09/11/17 at 3:38 PM, Staff E confirmed the RT assessments and monitoring were not completed at least every three hours per facility policy. Staff E stated respiratory therapy should have assessed the patient every 3 hours when on the ventilator and approximately every 3 hours for Ventimask per facility policy.

5. Review of the medical record for Patient #1 revealed an admission date of 07/13/17. The patient's diagnosis was acute respiratory failure. The medical record contained documentation that the patient was on Bipap at night and vapotherm (heated high flow oxygen per nasal cannula) during the day. The medical record lacked documentation of respiratory therapy assessments every three hours on 08/06/17 and 08/07/17. Respiratory therapy assessments were documented on 08/06/17 at 3:00 AM, 7:35 AM, 10:55 AM, 3:00 PM, 7:00 PM, and 11:00 PM; and on 08/07/17 at 3:00 AM, 7:00 AM, 11:30 AM, and 3:40 PM.

This finding was verified on 09/11/17 at 10:00 AM by Staff B.

6. Review of the medical record for Patient #5 revealed an admission date of 07/25/17. The patient's diagnosis was respiratory failure. The patient was on a ventilator. The medical record lacked documentation of respiratory therapy assessments every three hours on 08/20/17, 08/21/17, and 08/22/17. Respiratory therapy assessments were documented on 08/20/17 at 2:57 AM, 7:13 AM, 10:07 AM, 12:45 PM, 4:24 PM, 7:00 PM, and 10:30 PM; on 08/21/17 at 1:00 AM, 3:30 AM, 7:00 AM, 10:40 AM, 1:00 PM, 5:00 PM, 7:52 PM, and 10:49 PM; and on 08/22/17 at 3:35 AM, 7:00 AM, 11:00 AM, 1:00 PM, and 3:00 PM. This was verified on 09/11/17 at 12:00 PM by Staff B.

On 09/11/17 at 10:15 AM, the Respiratory Therapy Manager stated that patients with trachs and on ventilators required monitoring every four hours and all other patients required an assessment by respiratory therapy every shift. However, a review of the facility's policies revealed every 3 hour reassessment and monitoring.

A review of the RT Staffing tools for August and September 2017 revealed the tool included the number of hours RTs that were scheduled in patient care versus actual hours worked. Staff E confirmed on 09/12/17 between 9:00 AM-9:20 AM the facility did not meet the actual hours required in a 24 hour period for Respiratory Therapy as follows:

a) On 08/03/17 the actual RT hours scheduled to work in patient care were 24, which was 6.6 hours less than required to meet patients needs.
b) On 08/07/17 the actual RT hours scheduled to work in patient care were 24. Actual hours worked were 6.6 less than required to meet patients' needs.
c) On 08/11/17 the actual RT hours scheduled to work in patient care were 36. Actual hours worked were 4.8 less than required to meet patients' needs.
d) On 08/14/17 the actual RT hours scheduled to work in patient care were 36. Actual hours worked were 4.8 less than required to meet patients' needs.
e) On 08/16/17 the actual RT hours scheduled to work in patient care were 36. Actual hours worked were 8.2 less than required to meet patients' needs.
f) On 08/19/17 the actual RT hours scheduled to work in patient care were 36. Actual hours worked were 8.2 less than required to meet patients' needs.
g) On 08/21/17 the actual RT hours scheduled to work in patient care were 36. Actual hours worked were 8.2 less than required to meet patients' needs.

Staff E stated if the staffing hours are not met for at least 4 hours or greater in a 24 hour period for RT, it would be very challenging to care for patients. Staff E stated that a lack of 8.2 hours in a 24 hour period for 13 airway patients would be an excessive range of not staffed appropriately. Although Staff E stated he/she fills in on day shift where the majority of respiratory care occurs, there was no documentation of hours this employee worked as an RT providing care to patients in August 2017.

During this visit between 09/07/17 and 09/12/17, an interview was conducted with a Respiratory Therapist. This therapist stated he/she felt that where there when two RT's on duty, that was usually enough staff to provide safe patient care. Staff X stated that approximately two to three weeks ago only one RT was on the day shift and that things were hectic. The RT stated thankfully there were no Rapid Responses, and she/he managed to get through the day.

During this visit between 09/07/17 and 09/12/17, an interview was conducted with a different Respiratory Therapist. This RT stated it would be nice to have more staffing especially for patients with airways. The RT stated less than two RTs requires more time management skills and it's gotten more challenging to provide care for the respiratory patients. Staff E assists when called in on weekends, but due to the staffing ratio RT 1:7 patients, the workload is heavy and it's hard to work alone as the sole RT.

On 09/07/17 another Respiratory Therapist was interviewed. The RT stated the ratio used for staffing is seven airways per RT and ventilators, trachs, and ET tubes are included when calculating the airway ratio. The RT stated about two months ago the staffing ratio changed, it used to be five airways per RT and Bipap and high flow oxygen were then included in the airways count of patients. The RTs are responsible for ventilator management and weaning, trach care, ET tubes, Bipap, incentive spirometry, percussion, aerosol treatments, inhalers, and intubations. Since the staffing ratio has changed, the RT stated there is less time to care for each patient and for patient education.