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Based on observation, record review, and interviews the hospital failed to meet the Condition of Participation for Infection Control as evidenced by:

1. The hospital failed to designate an infection control officer responsible for developing and implementing policies governing control of infections and communicable diseases (see findings in A0748).

2. The hospital failed to ensure the Infection Control Program was implemented to prevent and control infections and communicable diseases (see findings in A0749).

a) failing to properly clean and store equipment apart from unclean equipment in a shower room and in the nurses' lounge;
b) storing dialysis machines in an unlocked and accessible bathroom with no designation to alert persons not to use the room for toileting or other purposes;
c) not ensuring rooms designated as cleaned and ready for a patient admission were clean;
d) staff entering the room of a patient on droplet isolation precautions without using required PPE (Personal Protective Equipment);
e) patients' (including isolation patients') clothing laundered in the same room in which food was refrigerated and sometimes prepared, with the refrigerator located next to the washing machine and dryer; and
f) having unlabeled patient and staff food in a refrigerator located in the ADL (Activities of Daily Living) room, which included out of date items.

Based on observation, record review, and interview the hospital failed to ensure
1. A system was in place to track physicians with delinquent medical records and failed to follow medical staff by-laws for physicians with delinquent medical records.
2. Medical records were properly stored to protect from water damage for approximately 200 medical records and from fire damage for all inactive medical records in the hospital for the last year.
Findings:

1. Review of the hospital's policy for Health Information Management, Types of Review revealed in part, "...2. Discharge Monthly Review - a final or discharge review will done 30 days after discharge...If deficiencies have not been completed within the 30 days time frame, the chart becomes delinquent. Medical staff members who have any delinquent charts will be presented to the MEC (Medical Executive Committee). The appropriate protocol that is outlined in the Medical Staff Bylaws and Deficiency Notification/Suspension policy will be strictly followed when dealing with any disciplinary actions that might need to be put into action. 3. Once the chart is complete, a final review must be performed prior to filing the chart as complete to ensure completeness of the record..."

Review of the hospital Medical staff bylaws revealed in part, "....c. A chart shall not be considered delinquent until thirty (30) days following discharge. Chart completion requirements are as follows:
All medical records shall be completed by the attending physician within 25 days of discharge.
The administrator and responsible physician will be notified of deficiencies pending completion periodically throughout the 25 day completion process via the HIM (Health Information Management) Coordinator.
If the records are not completed, within 25 days, the HIM coordinator will notify the Administrator. The Administrator/Designee will notify the responsible physician that his/her admitting/consulting privileges have been suspended until such time as the records are complete.
It shall be the responsibility of the HIM coordinator to notify the Administrator when the medical records are complete. Upon notification, the physician will be notified that his/her admitting privileges have been reinstated.
d. Any physician having staff privileges suspended due to incomplete medical records three (3) times in one quarter must appear before the executive medical staff prior to being reinstated..."

An interview was conducted with S3HIM (Health Information Management) Coordinator on 10/22/13 at 9:50 a.m. She reported there was no system currently in place to determine which physician had medical records deficient past 30 days and she could not tell which charts were deficient unless she purged the charts. S3HIM Coordinator also reported that none of the physicians had been suspended for incomplete charts and confirmed the hospital was not following their medical staff bylaws.

An interview was conducted with S1Administrator on 10/23/13 at 6:30 p.m. She reported she was aware that there was no system in place to track incomplete charts passed 30 days.

2. Review of the hospital's Health Information Management policy, Storage of Medical Records revealed in part, "...1. Storage A. The policies and procedures for storage and retrieval shall be developed to achieve the following: ....3. safeguard records and documents from tampering, loss, and advertent destruction...
III. Storage Space Specifications: Storage space shall be selected and maintained to protect records from unauthorized access, loss, and destruction. Storage space shall be selected to meet the following specifications:
adequate lighting
controlled environment (60 -80 degrees F, 50 percent humidity)
freedom from dust
freedom from hazards, such as flooding or damage from broken water pipes..."

Review of the hospital's policy titled Destruction of Medical Records revealed in part, "...1. Flooding/Water Damage: Medical records will be maintained in permanent storage in filing cabinet and/or drawer units that are raised from the floor to prevent flooding and/or water damage...2. Fire and Other damage: If records can't be removed prior to fire or other damage, the HIM Manager and the administrative team will then meet to determine what recovery mechanisms are feasible..."

An observation was made of a trailer housing administrative offices and medical records on the initial tour of the hospital on 10/21/13 at 10:30 a.m. In the trailer two (2) rooms were assigned to medical records. One room housed the medical records from the last year. These medical records were held in metal file cabinets with front cabinetry that were capable of being closed completely, securing the medical records from water damage. An observation was made of no sprinkler system or any other system in the trailer to protect any of the medical records from fire. The second room designated to medical records was for patient records that had been purged from the medical record files in the first room. These patient records were in 25 cardboard boxes with approximately 200 medical records in the boxes.

An interview was conducted with S11Assistant HIM Coordinator on 10/21//13 at 10:30 a.m. She reported the medical records in the second room in boxes were waiting for the contract agency to pick them up and take them to an offsite storage facility. She further reported the agency usually picks up the records every 3 months.

An interview was conducted with S1 Administrator on 10/21/13 at 10:40 a.m. She reported she was aware the medical records were not protected from fire and water damage.

A phone interview was conducted with S12RHIT (Registered Health Information Technician) on 10/23/13 at 5 p.m. She reported she was over the Medical Records Department at the hospital. She also reported that the hospital had discussed in the past how the patient's medical records were not protected from fire and water.

Based on interview and record review the hospital failed to ensure there was a qualified dietary manager based on education, training or experience to be responsible for the daily management of the dietary services as evidenced by lack of documented education or experience for the appointed dietary manager.
Findings:

An interview was conducted with S9RN(Registered Nurse) Dietary Manager on 10/23/13 at 2:05 p.m. She reported she worked full time at the hospital as a registered nurse and she also was appointed the hospital's dietary manager. She further reported some of her dietary duties were to check the patient's food to make sure the hot food was hot and cold food was cold and to oversee that patients received the correct therapeutic diet. When questioned if she had any special training or experience in dietary management, she reported that she did not.

Review of S9RN's personnel record revealed no documentation of special education, training or experience in dietary management and no competencies for duties or skills as the dietary manager.

An interview was conducted with S2RN, Director of Nursing on 10/23/13 at 5:30 p.m. She reported S9RN Dietary Manager had no special experience or training as the dietary manager.

Based on record review and interviews the hospital failed to designate an infection control officer responsible for developing and implementing policies governing control of infections and communicable diseases.
Findings:


In an interview 10/21/13 at 9:25 a.m., during a tour of the hospital, S4ADON (Assistant Director of Nursing) was asked who the hospital's designated Infection Control Coordinator was. S4ADON reported that everyone was responsible for infection control, but she would have to say S2DON (Director of Nursing) was over Infection Control.

In an interview 10/22/13 at 10:40 a.m. S2DON reported that S7Infection Control Consultant was the Infection Control Coordinator. The DON reported that S7 Infection Control Consultant was not frequently at the hospital, but had provided some in-services at the hospital and analyzed data that she (S2DON) collected on infections in hospital patients.

In a phone interview 10/23/13 at 10:20 a.m. S7Infection Control Consultant reported that she did not function as the Infection Control Coordinator for the hospital. She further reported that she was not actively involved in the hospital's Infection Control Program. S7Infection Control Consultant said that she was called (by the hospital staff) about issues as they arose. The Infection Control Consultant reported that she had, in the past, reviewed data collected, but the Infection Control was overseen by the DON.

In an interview 10/23/13 at 4:00 p.m. with S1ADM (Administrator), S2DON, and S4ADON present; the Administrator , DON ,and ADON were informed of S7Infection Control Consultant's report that she was not actively involved in the hospital's Infection Control Program and that she did not function as the Infection Control Program's Coordinator. S2DON stated that the hospital would be looking for a qualified and trained Infection Control Coordinator.

Based on observation, record review, and interviews the hospital failed to ensure the Infection Control Program was implemented to prevent and control infections and communicable diseases as evidenced by:
1) failing to properly clean and store equipment apart from unclean equipment in a shower room and in the nurses' lounge;
2) storing dialysis machines used for patient care in an unlocked and accessible bathroom with no designation to alert persons not to use the room for toileting or other purposes;
3) not ensuring rooms designated as cleaned and ready for a patient admission were clean;
4) staff entering the room of a patient on droplet isolation precautions without using required PPE (Personal Protective Equipment);
5) patients' (including isolation patients') clothing laundered in the same room in which food was refrigerated and sometimes prepared, with the refrigerator located next to the washing machine and dryer; and
6) having unlabeled patient and staff food in a refrigerator located in the ADL (Activities of Daily Living) room, which included out of date items.
Findings:

1) Failing to properly clean and store equipment apart from unclean equipment in a shower room and in the nurses' lounge.
An observation was made 10/21/13 at 9:25 a.m., during a tour of the hospital accompanied by S4ADON (Assistant Director of Nursing), of a patient shower room located off the end of the patient room hallway. Observed in the shower room were four (4) large shower chairs, a lap-buddy (covered foam device placed in a patient's lap, while in a wheelchair, to assist in prevention of a fall from the wheelchair) on the shower floor, and a piece of discolored, dried gauze on the shower floor. One of the shower chairs was noted to have rust and and piece of silk tape soiled with brown discoloration on one wheel. None of the equipment had any evidence to note whether it was supposed to have been cleaned. S4ADON verified the observations and reported there should have been some visible notification of the clean/dirty status of the equipment. The ADON further reported that the lap-buddy should not have been in the shower room or on the floor.
An observation was made on 10/21/13 at 10:25 a.m. of 56 oxygen cylinders stored in the nursing lounge. The oxygen cylinders were not separated by used and unused cylinders. S4ADON Director of Nursing reported the nurses have to check before they grab an oxygen tank for a patient to see which one has oxygen currently in the tank. Also in the nursing lounge was an uncovered EKG Machine with dust on the screen, uncovered bladder scan equipment, and 3 oxygen concentrators ( 2 uncovered and 1 covered with a plastic bag). S4ADON reported that she could not tell by looking at the tanks if any removed from patient rooms (including isolation patients) had been disinfected prior to placing them amongst the full oxygen tanks.
2) storing dialysis machines in an unlocked and accessible bathroom with no designation to alert persons not to use the room for toileting or other purposes.
An observation of a group of three (3) rooms off and open to the hospital hallway on 10/21/13 at 9:25 a.m. revealed one room labeled Bathroom that contained a toilet, sink, and a large Dialysis machine. S4ADON verified the observation and reported that that was one of two machines used by the contracted Dialysis service and that bathroom was the only place to store them, as they were short on storage space. The ADON further reported that all the staff knew not to use that bathroom. When asked how patients and/or visitors to the hospital would know not to use the bathroom since there was not a sign other than "Bathroom", she offered no answer.
3) Not ensuring rooms designated as clean and ready for a patient admission were clean.
An observation was made 10/21/13 at 10:00 a.m. of patient room "a" during a tour of the hospital with S4ADON. S4ADON reported that room "a" was clean and ready for a patient to occupy. The observation revealed discolored and soiled silk tape on the side rail of the bed closest to the door. Further observation revealed several areas of clear thickened dried material on the floor beside the side of the same bed on the side away from the hallway door. Also noted on the floor was tape stuck to the floor that was clear with brown discoloration in some areas. On the bedside tray beside the bed farthest from the hallway/entrance door was an area of deep brownish-red dried substance approximately 1 cm (centimeter) in diameter. S4ADON verified all observations. She reported that she was unable to identify the substance on the floor or on the over-bed tray. When both substances were easily removed with a wet paper towel, S4ADON verified that the room was not clean and ready for a patient.
4) Staff entering the room of a patient on droplet isolation precautions without using required PPE.
Review of hospital policy # III-D.4.27, Subject: Guidelines for Transmission-Based Isolation Precautions, issued 10/06, no review or revision date, and provided by S1ADM (Administrator) and S2DON as current revealed the following, in part: Policy: Transmission-Based Isolation Precautions will be used for patients infected with those pathogenic organisms which are not primarily bloodborne. Purpose: to protect individuals within the facility from bacterial and viral pathogens. Procedure: In addition to Standard Precautions used for every patient to prevent the spread of bloodborne pathogens, Transmission-Based Precautions are used to prevent the spread of pathogens transmitted through other means, i.e., contact, droplet, and airborne. Unlike PPE used to protect the healthcare worker from bloodborne pathogens, most of the attire required for transmission-based precautions is kept outside of the patient care areas, and donned before entering the patient's room,...Disposable PPE should not be reused and is to be discarded after single use... Droplet Precaution: Droplet precautions are designed to prevent the spread of respiratory pathogens that are carried by relatively large droplets of sputum which can project 3 feet or less. As droplet-transmitted organisms are often also contact organisms and contamination of the environment as well as mucus membranes can occur, an ordinary surgical mask with a visor or goggle and gloves are required. In some cases, where forceful expulsion of secretions often occurs with coughing and sneezing, a gown is also advisable...In an observation 10/21/13 at 9:45 a.m., accompanied by S4ADON, S5LPN (Licensed Practical Nurse) was observed entering the room of Patient #7, leaving the door open, and leaving about 5 minutes later. Also observed was a sign on the door that read, "Droplet Precautions" and a three (3) drawer plastic chest, just outside of Patient #7's room, with gloves, masks, disposable gowns, and biohazard bags (PPE). It was noted that the LPN did not use any PPE while in Patient #7's room. S4ADON verified that Patient #7 was on droplet isolation precautions due to a respiratory infection. The ADON further confirmed that S5LPN was supposed to have put on gloves and a mask before entering the patient's room. The ADON reported that the LPN was in the patient's room administering medications.
In an interview 10/22/13 at 2:40 p.m. S5LPN reported that she had failed to use PPE while administering medications to Patient #7 the previous day because she had been told in report that he was no longer on droplet isolation precautions. The LPN confirmed that the resident still had a sign on his door that read "droplet precautions". When asked if she had verified that with the physician, patient, patient's chart, etc. she said she had not. The LPN reported that with droplet precautions she should have at least had gloves and a mask on before entering the room. S5LPN also reported that Patient #7 was still on droplet isolation.
5)Patients' (including isolation patients') clothing laundered in the same room in which food was refrigerated and sometimes prepared, with the refrigerator located next to the washing machine and dryer.
Review of hospital policy #III-C.3.06, Issued 10/06, Revised 12/08, Environmental Cleaning, Subject: Soiled Linens, provided by S1ADM and S2DON as current, revealed in part the following: "Appendix A (Laundering of Patient Clothing) Soiled linen should be handled as little as possible and with minimal agitation to prevent gross microbial contamination to the air and of persons handling the linen. Procedure: * All linen will be bagged at the location of use which means the location where the clothes are received. If linen is wet and presents a reasonable likelihood of leakage or soak through the linen must be secured into another container to prevent leakage during transport. * Staff will wear gloves when placing clothing in the bag before transporting. * All patient clothing will be brought to the ADL room for processing. * All sorting of the patient's clothes will occur in the ADL room while wearing the appropriate PPE i.e., gloves gowns, face shields or goggles. ...
An observation of the ADL (Activities of Daily Living) room 10/21/13 at 9:35 a.m. revealed plates, pots, and serving utensils in a dish rack by a sink. Also noted in the area were the following: a stove/oven, refrigerator, clothes washer and dryer, 2 covered laundry hampers- one empty and one with linens, unmade patient bed, and a white towel on the floor on the opposite side of the room from the washer and dryer. The washer was in operation during the observation. The patients' laundry hampers were noted to have decorative cut out sections in the sides of the hamper and the clothes were not bagged. Further observation revealed that the washer and dryer were located next to the refrigerator and the clothes hampers were partially in front of the refrigerator. S4ADON reported that the refrigerator was used for staff food, the staff sometimes cooked in the area as the room was rarely used for ADL training. She further reported that the patients' laundry was washed daily by the CNAs (Certified Nursing Assistants) in this room. S4ADON verified that the patient's laundry in the hamper, yet unwashed, was not bagged.
In an interview 10/23/13 at 4:00 p.m. with S1ADM, S2DON, and S4ADON, S2DON confirmed that washing patient clothes (including isolation patients) in an area where food is stored and prepared is not an acceptable infection control practice. S1ADM nodded her head up and down at that time.
6) Having unlabeled patient and staff food items in the refrigerator located in the ADL room:
An observation of the ADL (Activities of Daily Living) room 10/21/13 at 9:35 a.m. revealed plates, pots, and serving utensils in a dish rack by a sink. Also noted in the area were the following: a stove/oven, refrigerator, clothes washer and dryer, 2 covered laundry hampers- one empty and one with linens, unmade patient bed, and a white towel on the floor on the opposite side of the room from the washer and dryer. The washer was in operation during the observation. S4ADON reported that the refrigerator was used for staff food, the staff sometimes cooked in the area as the room was rarely used for ADL training. She further reported that the patients' laundry was washed daily by the CNAs (Certified Nursing Assistants) in this room. Further observation revealed food items in the refrigerator freezer that included, in part the following: a sealed plastic bag with frozen ground meat labeled with only "4.68" and individual serving sized ice cream cartons. The ADON was unable to identify the contents of the bag of meat in the freezer and stated that it should not be in there. Observation of the refrigerator contents revealed patient and staff food. The patient food was graham crackers and sandwiches. The staff food consisted of salad dressing, sugar, cheese, tartar sauce, whipped cream, a partially empty tub of margarine with an expiration date of 8/13 and BBQ sauce. S4ADON verified the observations and said that patient food and staff food should not be kept together. When asked if soiled patient laundry should be next to the kitchen and food area, S4ADON offered no answer.
Review of an Infection Prevention Plan Evaluation, Executive Summary 2012 revealed, in part, that objectives included: #3: Conduct prevention activities to control/prevent infections and #5: Conduct surveillance activities based on the infection control risk assessment and identified hospital acquired infections and resistant organisms. Further review revealed the following: "Evaluation of Performance and Effectiveness- the infection prevention plan was not fully implemented as prescribed in the plan. the Data collection was fragmented and data was not collected on key indicators identified in the infection prevention plan risk assessment. Data was collected based on patient days as the data component which is not the recommended by the CDC. The recommended data component for calculating UTIs [Urinary Tract Infections] with a Foley is based on Foley days... Improvement opportunities identified were not consistently documented as to monitoring and resolution." 2013 Strategies included the following, in part: - provide ongoing staff infection prevention education, - implement hospital-wide infection prevention activities, and -Utilized the Infection Prevention Risk Assessment results to support infection prevention activities."
Review of the hospital's Infection Control Plan 2013 revealed, in part, priority focus areas as follows: F) Environmental Rounds: to be performed in the hospital... Feedback on opportunities for improvement to be presented at the monthly Performance Improvement Meeting and through to the PPC (Professional Practice Committee), MEC (Medical Executive Committee) and Governing Board, G) Isolation Rounds, H) Infection Control Plan Evaluation, I) Surveillance Reporting Structure, J) Infection Control Protocols -...Handwashing audits were to be conducted at random times through the month and included all disciplines having contact i.e., physicians, Nurse Practitioners, nursing staff, and therapy. Further review revealed strategies to minimize, reduce, or eliminate risks included, in part, auditing hand hygiene practices among all caregivers and staff education on appropriate storage, cleaning/disinfection, and/or disposal of supplies and equipment. Strategies to minimize, reduce, or eliminate risks included Staff education on appropriate storage, cleaning/disinfection, and/or disposal of supplies and equipment
In an interview 10/23/13 at 3:40 p.m. S2DON (Director of Nursing) reported that she collected the data in Infection Control. She explained that she broke down the hospital acquired versus community acquired (acquired before admission to the hospital) infections. S2DON reported that the total number of Hospital Acquired Infections for the year 2013 were as follows: Average number of patient days/ number of Hospital Acquired Infections for January: 384/7, February: 235/4, March: 375/3, April: 284/3, May: 356/3, June: 330/2, July: 271/4, August: 322/3, September 274/1. S1ADM reported the average daily census as 11.5 S2DON further reported that S4ADON (Assistant Director of Nursing) performed handwashing surveillance and environmental rounds. No documentation for environmental rounds done was provided. After reviewing the Infection Prevention Plan Evaluation Executive Summary 2012, S2DON confirmed that not all of the strategies suggested in the evaluation of the 2012 Infection Control Plan Evaluation were being followed and implemented. The DON verified that the concerns identified by surveyors had not been identified by the hospital

Based on record review and interview the hospital failed to have a full time respiratory therapist on staff and/or have competent nursing staff to perform respiratory therapy related physician's orders.
Findings:

Review of the hospital's policy for Respiratory Therapy, Subject: Meter dosed inhalers revealed in part, "...Upon order of the physician, the respiratory therapist will administer the inhalers as per order..."

Review of the hospital policy for Respiratory Therapy, Subject: Trach/Stoma Care revealed in part, "...The Respiratory Care Staff will provide proper and correct tracheostomy/stoma care on physician's order in order to keep stoma area clean, free of secretions, and less susceptible to infection..."

Review of the hospital policy for Respiratory Therapy, Subject: Airway Maintenance revealed in part, "....The Respiratory Therapist and registered nurse may perform orotracheal, nasotracheal, and tracheal suctioning..."

Review of the hospital policy for Respiratory Therapy, Subject: Cardiopulmonary Resuscitation revealed in part ,"...The Respiratory Care Department will provide trained individuals during all respiratory and cardiac arrest. The Respiratory Care Department will assist in maintaining an airway and ventilatory support equipment required during life-threatening situations..."

Review of the hospital policy for Respiratory Therapy, Subject: Emergency Medical Service without Physician's Order revealed in part, "...A respiratory therapist may administer life-saving treatment in the absence of a physician's order, but the physician is to be notified as soon as possible..."

Review of the hospital policy for Respiratory Therapy, Protocols revealed in part,"...Upon physician's order, the Respiratory Therapy Department will implement oxygen, bronchopulmonary hygiene or hyperinflation protocol..."


An interview was conducted with S2DON (Director of Nursing) on 10/22/13 at 11 a.m. She reported that S13MD(Medical Doctor) was the Director of Respiratory. She further reported the types of patients with respiratory problems that were admitted to the facility were: oxygen dependent patients, patients on incentive spirometry, metered dose inhalers, CPAP/BIPAP (Continuous positive airway pressure/bi-level positive airway pressure), and nebulizers, and patients with established tracheostomies. S2DON reported the hospital had one respiratory therapist that worked on a as needed bases (S10RT, Respiratory Therapist). S10RT typically helps with some training and works on the Performance Improvement Plan for respiratory therapy. S2DON reported S10RT typically only comes into the hospital an hour at a time. S2DON also reported that the hospital does competency training once a year for the nursing staff. She went on to report the training was a two day training program in order to catch all of the nursing shifts. S2DON reported S10RT did the training for one of the days and S4ADON (Assistant Director of Nursing) did the training for the other day. S2DON went on to report the competency training was done once a year and if a new nurse was hired the month after the training, she would receive the competency training the next year. S2DON reported that the hospital did not have wall oxygen, and that was why the hospital maintained the large amount of oxygen cylinders.

Review of the personnel file for S4ADON and S10RT revealed no competency training for any type of respiratory therapy. Review of the Employee Competency Record packet revealed the patient care nurses were trained on only Metered Dose Inhalers, oxygen and nebulizers.

Review of the Credentialing files with S3 HIM Coordinator revealed that S14MD was the Respiratory Director not S13MD as reported by S2DON.

Review of Respiratory Performance Indicators from 7/13 through 9/13 revealed 390 nebulizer treatments were delivered, 1356 oxygen checks were completed, 1446 incentive spirometry treatments were done, and 175 MDIs (metered dose inhalers) were administered in the hospital in a 3 month period.

Based on record review and interviews the hospital failed to ensure the nursing staff was competent to perform respiratory care and carry out respiratory related physician's orders on patients requiring respiratory care as evidence by being trained by staff not deemed as competent.
Findings:

Review of the hospital's policy for Respiratory Therapy, Subject: Meter dosed inhalers revealed in part, "...Upon order of the physician, the respiratory therapist will administer the inhalers as per order..."

Review of the hospital policy for Respiratory Therapy, Subject: Trach/Stoma Care revealed in part, "...The Respiratory Care Staff will provide proper and correct tracheostomy/stoma care on physician's order in order to keep stoma area clean, free of secretions, and less susceptible to infection..."

Review of the hospital policy for Respiratory Therapy, Subject: Airway Maintenance revealed in part, "....The Respiratory Therapist and registered nurse may perform orotracheal, nasotracheal, and tracheal suctioning..."

Review of the hospital policy for Respiratory Therapy, Subject: Cardiopulmonary Resuscitation revealed in part ,"...The Respiratory Care Department will provide trained individuals during all respiratory and cardiac arrest. The Respiratory Care Department will assist in maintaining an airway and ventilatory support equipment required during life-threatening situations..."

Review of the hospital policy for Respiratory Therapy, Subject: Emergency Medical Service without Physician's Order revealed in part, "...A respiratory therapist may administer life-saving treatment in the absence of a physician's order, but the physician is to be notified as soon as possible..."

Review of the hospital policy for Respiratory Therapy, Protocols revealed in part,"...Upon physician's order, the Respiratory Therapy Department will implement oxygen, bronchopulmonary hygiene or hyperinflation protocol..."

An interview was conducted with S2DON(Director of Nursing) on 10/22/13 at 11 a.m. She reported the types of patients with respiratory problems that were admitted to the facility were: oxygen dependent patients, patients on incentive spirometry, metered dose inhalers, CPAP/BIPAP (Continuous positive airway pressure/bi-level positive airway pressure), and nebulizers, and patients with established tracheostomies. S2DON also reported the hospital had one respiratory therapist that worked on a as needed basis, S10RT(Respiratory Therapist). She reported S10RT typically helps with some training and works on the Performance Improvement Plan for respiratory therapy. S10RT typically only comes into the hospital an hour at a time. S2DON further reported that the hospital does competency training once a year for the nursing staff. She stated it was a two day training program in order to catch all of the nursing shifts. S2DON reported S10RT did the training for one of the days and S4ADON(Assistant Director of Nursing) did the training for the other day. S2DON went on to report the competency training was done once a year and if a new nurse was hired the month after the training, she would receive the competency training the next year. S2DON reported that the hospital did not have wall oxygen, and that was why the hospital maintained a large amount of oxygen cylinders.

Review of the personnel file for S4RN Assistant Director of Nursing and S10 Respiratory Therapist revealed no competency training for any type of respiratory therapy. Review of the Employee Competency Record packet revealed the nurses were trained on only Metered Dose Inhalers, oxygen and nebulizer's.

Review of Respiratory Performance Indicators from 7/13 through 9/13 revealed 390 nebulizer treatments were delivered, 1356 oxygen checks were completed, 1446 incentive spirometry treatments were done, and 175 MDIs (metered dose inhalers) were administered in a 3 month period in the hospital.