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Based on interviews and observation, the facility failed to ensure any medical staff providers (Medical Doctors, Doctors of Osteopathy, Nurse Practitioners, Physician Assistants, etc.) had adequate training on how to set-up and adjust ventilators (a machine that helps a patient breathe or breathes for them), bi-pap (non-invasive ventilation that helps a patient breathe), or high-flow machines (heated humidified air delivered at high pressure through nasal prongs) to provide care to meet patient needs. This deficient practice could lead to delays in care and potential patient harm because medical staff cannot operate medical equipment.

A. During an interview on 09/03/25 at 2:15 pm with S(Staff)14, non-clinical and S(Staff)15, non-clinical, it was confirmed that competency training on respiratory equipment such as ventilators, bi-pap, and high-flow machines was not required by the facility for medical staff personnel.

B. During an interview on 09/02/25 at 3:15 pm with S(Staff)8, clinical, it was stated "I am not trained to set up a machine [referring to a ventilator]."

C. During an interview on 09/02/25 at 4:36 pm with S14, non-clinical, it was reported that only one employee from the facility attended the seminar titled "Current Concepts in Mechanical Ventilation", presented on July 25, 2025. The employee is a respiratory therapist, not a medical provider.

D. During an observation on 9/4/25 at 2:00 pm, the facility was unable to produce competency validation checklists or other education documentation pertaining to ventilators, bi-pap, or high-flow machines for any medical provider on staff.

Based on observation and record review, the facility failed to ensure that 2 out of 2 ventilators (machines which help patients breathe or breathes for them) and 1 out of 1 bronchoscope (a thin tube used in a bronchoscopy procedure used to examine an airway) were inspected, tested, and maintained within their scheduled time periods to ensure performance, quality, and safety. This deficiency can lead to delays in care and potential patient and staff harm from potentially improperly functioning equipment.

A. During observation on 09/02/25 at 2:53 pm, the ventilator in the supply closet was found to be without a biomed sticker (a mandatory safety and inspection label for medical equipment).

B. During observation on 09/02/25 at 2:55 pm, the ventilator in the patient care area had an expired biomed sticker dated February, 2025.

C. During observation on 09/02/25 at 2:57 pm, the single available bronchoscope in the facility had an expired biomed sticker dated August, 2025.

D. Record review of the facility's policy 02/22/25 "PHS Medical Equipment Management Plan 10" states:
a. "The Hospital identifies high risk medical equipment on the inventory for which there is risk of serious injury or death to a patient or staff member should equipment fail." (page 3).
b. identifies ventilators as an example of High Risk equipment (page 3).

Based on record review, the facility failed to ensure staff roles and responsibilities are specified in writing, either through job descriptions or policy, when supporting patient respiratory needs via ventilator (a machine that helps a patient breathe or breathes for them), bi-pap (non-invasive ventilation that helps a patient breathe), or high-flow machines (heated humidified air delivered at high pressure through nasal prongs). This can lead to delays in care and potential patient harm because staff cannot operate medical equipment.

A. Record review of facility's policy 10/27/23 "ED.PDS.016 Registered Respiratory Therapist Guidelines for Care in the Emergency and Urgent Care Department" does not specify respiratory therapist responsibility for ventilator, bi-pap, or high-flow machines.

B. Record review of facility's policy 12/20/22 "PUL.PDS.106 Ventilator Management" under "Therapist Responsibility," it only specifies documentation responsibilities. It does not designate a responsibility to set up, monitor, or adjust ventilator settings.

C. Record review of facility's policy 04/25/25 "PC.PDS.288 Paramedic Guidelines for Care in The Emergency and Urgent Care Department" refers to "CPAP/BIPAP Monitoring" in Addendum B. The policy does not delineate paramedic responsibility to set up ventilators, bi-pap, or high-flow machines or to monitor a ventilator or high-flow machine.

D. Record review of facility's policy 04/21/25 "NSG.PDS.138 Emergency Department Nursing Guidelines for Care" does not delineate any nursing responsibility for either set up or monitoring of ventilators, bi-pap, or high-flow machines.

E. Record review of the facility's job description for a respiratory therapist describes ventilator management only. It does not specify ventilator setup, or setup/monitoring of bi-pap and high-flow machines.

F. Record review of the facility's job descriptions for EMT-P (emergency medical technician-paramedic), charge registered nurse, registered nurse, and licensed practical nurse do not delineate responsibilities to setup or monitor ventilators, bi-pap, or high-flow machines.