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Based on interviews and record review, the facility failed to ensure there was a documented full-time or part-time director of Respiratory Care Services who is a Doctor of Medicine (DOM) or Osteopathy (DO).

This failure resulted in the Respiratory Care Services not having a DOM or DO with the knowledge and experience to supervise and administer the Respiratory Care Services Department.

Findings:

During an interview with the Manager Respiratory Therapy (MRT) on 9/4/25 at 9:00 a.m., MRT indicated that he reported to the Nursing Director (ND 2), a Registered Nurse. The MRT further indicated that there was no Medical Director for the Respiratory Care Services.

During an interview with ND 2 and MRT on 9/4/25 at 9:25 a.m., ND 2 indicated, MRT reported directly to ND 2 and ND 2 reported to the Chief Nurse Executive (CNE). ND 2 acknowledged that there was no Medical Director for the Respiratory Care Services.

During a concurrent interview and record review with the Quality and Safety Oversight Specialist (QSOS) on 9/4/25 at 11:30 a.m., the facility's Organizational Charts titled "[Facility Name] Administrative Leadership Team for the Hospital and the Medical Group" was reviewed. The QSOS acknowledged there was no Medical Director responsible for the Respiratory Care Services on the Organizational Charts.

During a review of the facility's policy and procedure (P&P) titled, "Respiratory Care Services Plan for the provision of Care," approval date 2/25, the P&P indicated, "The inpatient Respiratory Care Department provides respiratory care services to inpatients and managers and operates the Blood Gas Laboratory [analyzes a sample of blood to see how well the lungs are working] (in conjunction with the clinical lab) ... The Respiratory Care Department operates under the standards of the community and individual licensed requirements of the Respiratory Care Practice Act, State of California ... The Respiratory Care Manager in conjunction with the [Facility Name] Site Supervisor has accountability and responsibility to assure that the program is in place ..." The Policy did not indicate whether a DOM or DO was required to oversee the Respiratory Care Department.