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Based on medical record review, facility policy review, and staff interview, the facility failed to ensure the use of restraints was in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraints by hospital policy (A168). The facility failed to ensure the condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff at an interval determined by hospital policy (A175).

Based on medical record review, facility Scope of Service review, staff interview, and facility policy review, the facility failed to ensure there were adequate numbers of respiratory therapists, respiratory therapy technicians, and other personnel who meet the qualifications specified by the medical staff (A1154). the facility failed to ensure services were delivered in accordance with medical staff directives (A1160).

Based on medical record review, facility policy review, and staff interview, the facility failed to ensure the use of restraints was in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraints by hospital policy for one of five patients reviewed with restraints (Patient #1). The total census was ten patients. The facility census was 18.

Findings include:

Review of the medical record for Patient #1 revealed the patient was admitted to the facility on 05/23/23 at 11:55 PM with diagnoses including Type II diabetes and morbid obesity with a body mass index of 41. The attending physician's History and Physical further revealed the patient was diagnosed with pneumonia on 05/09/23 requiring intubation due to acute respiratory failure and metabolic encephalopathy. According to the History and Physical, a tracheostomy was performed on 05/15/23. The patient also required a percutaneous endoscopic gastrostomy (PEG) tube on 05/22/23.

A nurse's note on 06/02/23 at 9:00 PM stated bilateral soft wrist restraints were applied due to the patient attempting to pull on her tracheostomy. The medical record lacked documentation of a physician order for the restraints until 06/03/23 at 4:00 AM, seven hours after the restraints were initiated.

The facility policy titled, Restraints, last reviewed on 01/2023, was reviewed on 06/05/23 at 12:35 PM. The policy instructed staff if the need for a restraint occurs so quickly that an order cannot be obtained prior to the application of restraint, the order must be obtained either during the emergency application of the restraint or immediately (within a few minutes) after the restraint has been applied.

The medical record of Patient #1 was reviewed with Staff B on 06/08/23 at 2:00 PM confirming the restraints were applied at 9:00 PM and the order was not received until seven hours later at 4:00 AM.

This deficiency represents non-compliance investigated under Substantial Allegation OH00143322.

Based on medical record review, facility policy review, and staff interview, the facility failed to ensure the condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff at an interval determined by hospital policy for two of five patients reviewed with restraints (Patient #1 and Patient #3). The total sample was ten patients. The facility census was 18.

Findings include:

1. Review of the medical record of Patient #3 revealed the patient was admitted to the facility on 03/23/23 with diagnoses including cardiac arrest following a lightning strike in 2016 while working outdoors, followed by hypoxic ischemic encephalopathy, frontal lobe deficits, cognitive and mood/behavior disturbances, agitation with violent behavior, and subsequent hospitalization since 2016 due to traumatic brain injury and debility related to his injury.

A physician ordered bilateral soft wrist restraints and hand mitts on 03/23/23 as notes revealed that the patient frequently pulled at medical devices and exhibited violent behavior including biting, kicking, and hitting staff. The patient has continued to require restraints since admission as his agitation with violent behavior has not improved.

The patient's medical record was reviewed for restraint specific documentation including review of physician orders, staff monitoring, and documentation of use, reduction, when possible, to include removal of hand mitts. Review of the Restraint Management Flow Sheet dated 06/05/23 revealed the required every two hour restraint assessment was completed from 7:00 AM to 11:00 PM. The assessment included review and update of the plan of care, patient/family education as needed, restraint release/reposition, mental status, offer of fluids/nutrition, offer of toileting, check of skin/circulation, turn/position change, personal hygiene, and respiratory check. The medical record lacked documentation of completion of the required every two hour restraint assessment from 12:00 AM- 8:00 AM, an eight hour period. There were no nursing progress notes indicating there were any incidents that prohibited the completion of the restraint assessment.

2. Review of the medical record for Patient #1 revealed the patient was admitted to the facility on 05/23/23 at 11:55 PM with diagnoses including Type II diabetes and morbid obesity with a body mass index of 41. The attending physician's History and Physical further revealed the patient was diagnosed with pneumonia on 05/09/23 requiring intubation due to acute respiratory failure and metabolic encephalopathy. According to the History and Physical, a tracheostomy was performed on 05/15/23. The patient also required a percutaneous endoscopic gastrostomy (PEG) tube on 05/22/23.

A nurse's note on 06/02/23 at 9:00 PM stated bilateral soft wrist restraints were applied due to the patient attempting to pull on her tracheostomy.

Review of the Restraint Management Flow Sheet revealed the medical record lacked documentation of every two hour restraint assessments until 06/03/23 at 7:55 AM.

The facility policy titled, Restraints, last reviewed on 01/2023, was reviewed on 06/05/23 at 12:35 PM. The policy instructs staff nurses to observe the patient and document the following every two hours:

* Restraint status
* Ensure proper placement
* Range of motion/ambulation
* Position
* Fluid/Nourishment
* Toileting
* Personal Hygiene
* Behavior Observation
* Level of Consciousness/Orientation

Staff B was interviewed on 06/08/23 at 12:00 PM. It was confirmed that the medical record of Patient #3 lacked documentation a staff nurse performed the required assessment of the patient's restraints every two hours for eight hours from 12:00 AM to 8:00 AM.

The medical record of Patient #1 was reviewed with Staff B on 06/08/23 at 2:00 PM confirming no documentation was found the restraint status was assessed every two hours between 9:00 PM on 06/02/23 and 7:55 AM on 06/03/23.

This deficiency represents non-compliance investigated under Substantial Allegation OH00143322.

Based on medical record review, staff interview, and facility policy review, the facility failed to ensure a registered nurse supervised and evaluated the nursing care for one of ten patients reviewed (Patient #3). The facility census was 18.

Findings include:

Review of the medical record of Patient #3 revealed the patient was admitted to the facility on 03/23/23 with diagnoses including cardiac arrest following a lightning strike in 2016 while working outdoors, followed by hypoxic ischemic encephalopathy, frontal lobe deficits, cognitive and mood/behavior disturbances, agitation with violent behavior, and subsequent hospitalization since 2016 due to traumatic brain injury and debility related to his injury.

A physician order for a stool culture was noted on 05/09/23. There were no results located for the stool culture in the medical record.

Staff B was interviewed on 06/09/23 at 9:10 AM and asked to locate the results for the stool culture. No results were located. It was confirmed that the physician ordered a stool culture on 05/09/23, however on 06/09/23, a month later, the medical record lacked documentation any sample was collected or resulted.

Based on medical record review, facility Scope of Service review, staff interview, the facility failed to ensure there were adequate numbers of respiratory therapists, respiratory therapy technicians, and other personnel who meet the qualifications specified by the medical staff. The facility had ten patients requiring respiratory services at the time of the survey. The total census was 18.

Findings include:

1. The facility Scope of Service was reviewed on 06/05/23 at 4:55 PM. According to the Scope of Service, the hospital is licensed for 44 beds and provides care to patients age 18 and older. The Scope of Service revealed the facility provides respiratory care to it's patients. Respiratory care provides services for the assessment, diagnostic evaluation, treatment, and monitoring of patients with deficiencies and abnormalities of cardiopulmonary function. The services of the respiratory care department are available to all patients seven days a week, 24 hours a day. As needed staff is available to assist with census fluctuations.

Staff N was interviewed on 06/06/23 at 2:35 PM. Staff N revealed that respiratory therapists were required to respond to any code blues and rapid responses. Staff N further stated that respiratory therapists were required to provide care to ventilator dependent patients and patients with a tracheostomy every four hours. She explained that the Manager of Respiratory resigned in 12/22 and the department had been without consistent leadership since that time. Staff N explained that this manager staffed the units with a minimum of two respiratory therapists if there were six or more patients on ventilators but currently there was often only one respiratory therapist with 10 ventilator patients. One respiratory therapist was forced to do the work previously done by two respiratory therapists. She further explained that a great deal of patients receiving care at the facility were ventilator dependent requiring weaning off the ventilator. She stated a patient's hospitalizations was often lengthened due to not being properly weaned from the ventilator due to inadequate staffing. Staff N reported there had been periods of time when there was no respiratory therapist available to patients.

Staff L was interviewed on 06/07/23 at 3:22 PM. Staff L stated that staffing the units with an adequate number of respiratory therapists had been a "significant challenge" since 12/22. There were often times when the respiratory therapist scheduled to work did not show up for their shift leaving the units without a respiratory therapist. Staff L stated the ability to wean was crucial and the ability to wean was being jeopardized due to not having adequate staffing.

The daily staffing sheets from 05/01/23 through 06/07/23 were reviewed on 06/08/23 at 1:30 PM. The staffing sheets listed the names of all healthcare workers working each shift. The staffing sheet for 05/19/23 listed the name of one respiratory therapist scheduled to work from 7:00 AM to 7:00 PM. A note next to the name of this respiratory therapist revealed he called off. The name of a second respiratory therapist was hand written below the type written name of the initial respiratory therapist. The actual time card for the replacement respiratory therapist revealed he worked from 11:45 AM to 4:00 PM, a total of 4.25 hours. Staff A and Staff B were interviewed on 06/08/23 at 4:12 PM. The staff members were asked to provide documentation of a respiratory therapist working from 7:00 AM to 11:45 AM. A time card for a respiratory therapist typically working in the rehab facility was provided. The time card revealed this respiratory therapist clocked into the facility at 9:00 AM.

Staff A and Staff B were interviewed on 06/09/23 at 10:00 AM. It was confirmed that there was no respiratory therapist for two hours, from 7:00 AM to 9:00 AM.

Review of the census sheet revealed the census on 05/19/23 was 19 and eight of the 19 patients were on ventilators. The daily staffing sheet for night shift on 05/24/23 revealed there was no respiratory therapist for one hour, from 2:00 AM to 3:00 AM. The census on 05/24/23 was 19 and 10 of the 19 patients were on ventilators. On 05/25/23, the daily staffing sheet for night shift revealed the scheduled respiratory therapist was removed as he resigned from the facility. The names of two respiratory therapists were hand written below the name of the scheduled respiratory therapist. The hours of 7:00 PM to 3:00 AM were listed next to the first name and the hours of 3:00 AM to 7:00 AM were listed next to the second name indicating the hours of the two respiratory therapists together covered the entire 12 hour shift. The names of the respiratory therapists were compared to a list of facility staff. The name of the respiratory therapist working from 7:00 PM to 3:00 AM was not listed as a respiratory therapist but instead she was listed as a registered nurse. The time card for this registered nurse, Staff H, revealed she worked 20.45 hours on 05/25/23, 7:00 AM to 7:00 PM as a charge nurse and 7:00 PM to 3:00 AM as a respiratory therapist.

Staff H was interviewed on 06/09/23 at 1:00 PM. Staff H was asked if in addition to being a registered nurse, she was also a licensed respiratory therapist. Staff H stated that she was not a licensed respiratory therapist and had never been a licensed respiratory therapist prior or after becoming a registered nurse. Staff H was asked if she often functioned as a respiratory therapist to which she replied, she could recall having done so one other time but could not remember that specific date. Staff H stated that she only provided suctioning on the day she was identified as the respiratory therapist, a task she has received training to perform. Staff H further stated that none of the patients were in distress and denied performing any tasks out of her scope of practice. Review of the medical records of the patients hospitalized on 05/25/23 revealed Staff H's initials next to the box labeled suctioning in each medical record where the patient required suctioning.

On 05/26/23, the daily staffing sheet revealed there was no respiratory therapist from 3:00 AM to 6:30 AM.

2. Review of the medical record of Patient #4 revealed the patient was admitted to the facility on 04/27/23 at 10:58 AM with diagnoses including aortic stenosis, functional quadriplegia, Parkinson's disease, Barrett's esophagus, and respiratory failure secondary to recurrent bilateral effusions and mucous plugging with prolonged ventilatory requirements resulting in a tracheostomy and PEG tube in 07/22. The patient had been ventilator dependent since then.

A nurse's note on 05/19/23 at 6:50 AM stated the respiratory therapist was at the bedside of the patient suctioning the patient. A stat chest xray was ordered for a suspected mucous plug. The note further stated the head of the patient's bed was elevated and the physician was notified. A nurse's note at 8:00 AM stated the patient was now lethargic and the nurse was unable to assess the patient's orientation. The note further stated that during shift report it was communicated that the patient had to be bagged a couple of times during the night due to low oxygen levels. The pulmonary physician was messaged at 8:20 AM with details of the patient the night before. At 8:42 AM a nurse's note revealed the patient was having desaturations in his oxygen. The pulmonary physician was informed. The physician advised the staff nurses to prepare for an emergent bronchoscopy. The nurse stated that she called the respiratory therapist that worked in the hospital where the facility was located for "help."

The physician's bronchoscopy note stated he was notified by nursing staff regarding hypoxic episodes overnight requiring bagging. The physician's evaluation of the patient prior to the bronchoscopy that morning noted the patient was markedly tachypneic with a respiratory rate in the high 30's. No consent was obtained prior to the procedure secondary to the "urgent nature" of the procedure. The patient tolerated the procedure well and there were no complications.

Staff B was interviewed on 06/08/23 at 11:00 AM. It was confirmed that there were times when respiratory therapists were not in house as indicated in the Scope of Service.

Staff K was interviewed on 06/08/23 at 4:55 PM. He confirmed that a respiratory therapist came from across the street at the facility's rehab facility. Staff K expressed concern that there was no respiratory therapist waiting to assist him with the emergency bronchoscopy until he requested that the respiratory therapist come over.

This deficiency represents non-compliance investigated under Substantial Allegation OH00143322.

Based on medical record review, staff interview, and facility policy review, the facility failed to ensure services were delivered in accordance with medical staff directives for one of 10 medical records reviewed (Patient #2). The facility census was 18.

Findings include:

Review of the medical record of Patient #2 revealed the patient was admitted to the facility on 05/16/23 at 3:38 PM with a past medical history significant for COVID-19 pneumonia with acute respiratory distress syndrome complicated by multiple cerebral infarcts, left hemiplegia, paroxysmal atrial fibrilation, and depression. The patient required tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube (feeding tube) placement following COVID-19 pneumonia.

On 05/27/23 the Respiratory Care Flowsheet noted ventilator rounds at 7:00 AM and at 4:41 PM. A note composed by a respiratory therapist at 3:07 PM stated she was unable to provide the every four hour ventilator checks due to inadequate staffing.

The facility policy titled, Mechanical Ventilation, revised on 01/20/20 and last reviewed on 04/17/23, was reviewed on 06/08/23 at 9:20 AM. According to the policy, respiratory therapists are required to provide and document routine ventilator rounds every four hours.

Staff B was interviewed on 06/08/23 at 11:00 AM. It was confirmed that the ventilator checks were not performed every four hours as required by facility policy.

This deficiency represents non-compliance investigated under Substantial Allegation OH00143322.