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Based on record review and interview, the hospital failed to collect, analyze and track critical incidents to incorporate into their performance improvement process in 12 of 15 critical incidents (6 rapid response calls, 2 code 4's, 2 transfers to an emergency room, 2 patient incidents and one complaint regarding patient care) identified in 4 of 11 inpatients (Patient # 12, #3, #6 and #7) and failed to be responsible and accountable for the Quality Assurance and Performance Improvement (QAPI) program when it failed to be responsible for the implementation of 5 of 8 Quality Scorecard Indicators (medical records delinquency rate, falls rates, ventilator wean rate, wounds healed, and patient satisfaction).

Findings include:

The Hospital failed to collect critical incidents to incorporate into their performance improvement process. (See Tag A-0273)

The Hospital failed to be responsible and accountable for the Quality Assurance and Performance Improvement program. (See Tag A-309)

The cumulative effect of these systemic problems results in the hospital's inability to provide safe patient care for it's patients with potential adverse outcomes.

Based on record reviews and interviews this facility's Executive Staff failed to enforce their Medical Staff Bylaws and Rules and Regulations as evidenced by the reappointments of their Medical Staff in 4 of 27 reappointments and failure of its Licensed Independent Practitioners to supervise and direct their Allied Health Practitioners according to their Medical Staff Bylaws and Rules and Regulations in 2 of 11 Patients (Patient #3 and #9).

Findings include:

The Medical Staff failed to follow their Medical Staff Bylaws and Rules and Regulations. (See Tag A-0339)

The Hospital Board failed to enforce appropriate actions when making reappointments of their Medical Staff. (See Tag A-340)

The cumulative effect of these systemic problems results in the hospital's inability to provide safe patient care for it's patients with potential adverse outcomes.

Based on record review and interview, the facility failed to collect, analyze and track critical incidents to incorporate into their performance improvement process in 12 of 15 critical incidents (6 rapid response calls, 2 code 4's, 2 transfers to an emergency room, 2 patient incidents, and one complaint regarding patient care) identified in 4 of 11 inpatients (Patient # 12, #3, #6 and #7).

Findings include:

Record review of policy titled "Critical Incidents" publication # QM 12, dated March 1997, last reviewed July 2017 under 13.1 Policy "A critical incident (formerly referred to as an unusual occurrence) report will be completed for any incident deemed to be inconsistent with the normal or routine operation of a Post Acute Medical (PAM) facility or the care of patients". Under 13.2.1.5 "Staff will report critical incidents through the use of the ORS [occurrence reporting system] system". Under Completing reports 13.2.2.1 "Any employee who witnesses or has knowledge of a critical incident shall, as soon as possible, complete the report on ORS".Under 13.2.2.2 "a critical report must be completed when one of the following has occurred...A complaint regarding patient care made by a patient, family member, or visitor... Anytime a Code is Called, Anytime a patient is transported out of the facility to an ER" (emergency room).

Record review of policy titled "Quality Assurance and Performance Improvement (QAPI) Plan, #QM3 dated 9/01/2014 reviewed last 7/05/2017, under policy revealed "This program has the responsibility for monitoring every aspect of patient care...in order to identify and resolve any breakdowns... The overall objectives of the QAPI Plan are to collect data to monitor the organizations performance", under 2. "Several global indices are used to monitor performance hospital-wide. These may include...f. results of resuscitation and effectiveness of response to change or deterioration in patients condition" and under 4. Function of the QAPI Committee: b. "working to create a culture of safety and continuous performance improvement c. Receiving, evaluating, and coordinating all reports submitted relating to the monitoring of quality of care and patient safety".

Record review of Policy titled "Rapid Response" #NSF 45 dated September 2013, reviewed last April 2017 under procedure revealed "Examples of criteria for consulting the Rapid Response Team - Staff member is worried about the patient, Acute change in heart rate <50 or > 130, Acute change in systolic blood pressure <90 or > 200, Acute change in respiratory rate <10 or >24, Acute change in saturation , 90% despite oxygen or > 20% difference in FiO2 requirement in 12 hours, Acute change in conscious state, Acute change in urinary output < 30 ml/hr (milliliter per hour), Acute significant bleeding, seizures, Chest pain, Fall with potential injury or unknown cause".

Record review of Rapid Response Team Protocol received 12/20/17 at 8:32 AM under Purpose: revealed "To provide the Rapid Response Team with immediate interventions to be taken pending physician contact. These interventions will be recorded in the medical record as a protocol and have been formally approved by the facility Medical Executive Committee".

Review of Patient #12's medical record revealed Rapid Response was called four times, on 12/02/16 at 4:26 AM, 12/07/16 at 12 PM, 12/10/16 at 2:10 PM and 12/25/16 at 12:17 PM which turned into a code 4 situation. Patient #12 was transferred to an acute care emergency room.

Interview with Quality Director B on 12/20/17 at 12:30 PM confirmed there were no incident reports for Patient #12 on the rapid responses called on 12/2/16, 12/07/16, 12/10/16 and 12/25/16 or the transfer to an Emergency Room.

Review of Patient #3's medical record revealed Rapid Response was called on 12/03/16 at 10:05 AM, Rapid Response Team Record # PAM-0101-AB (10/13) dated 12/03/17 was incomplete, notification of physician was not documented.

Interview with Quality Director B on 12/20/17 at 12:30 PM confirmed there were no incident reports for Patient #3 on the rapid response called on 12/03/16.

Review of Patient #6's medical record Nursing Daily Flowsheet dated 12/16/17 under Auxiliary Notes at 3:15 AM revealed "Patient removed trach [tube used for breathing] while primary nurse at lunch break. Trach reinserted by RT"(Respiratory Therapist). Respiratory Notes dated 12/16/17 revealed "RRT [Rapid Response Team] called @ [at] 02:30. Pt. [patient] decannulated self. Supervisor replaced with same size trach without incident". Resuscitation Report Supplement Form #PAM-0129 (10/13) dated 12/18/17 at 1 AM revealed "rapid response called and patient went pulseless. Code four called". Interdisciplinary Progress Note dated 12/18 at 1:40 AM revealed "sister called back yelling that we are going to kill her... sister was upset because pt [patient] was put back in restraints...sister has called three times repeatedly demanding staff send her sister out because we are killing her... called report to ER [Emergency Room]... pt left @ 05:00".

Interview with Charge Nurse N on 12/20/17 at 11:55 AM N stated that Patient #6 had pulled out his/her trach while the family was in the room. When asked for the incident report, N stated s/he did not have access to the ORS (occurrence reporting system) to put it in.

Interview with Case Manager Director O on 12/20/17 at 11:55 AM, O confirmed "these incidents should have been written up in the ORS" (occurrence reporting system).

Interview with Quality Director B on 12/20/17 at 12:30 PM confirmed there were no incident reports in the system on Patient #6 pulling out his/her trach, Patient #6's family discussion on need for restraints, on the rapid response dated 12/18/27, or on the transfer to an Emergency Room.

Review of Patient #7's medical record revealed Rapid Response was called on 12/15/17 at 4:50 PM, Nursing Daily Flowsheet dated 12/15/17 under Auxiliary Notes revealed "Patient called 911, police arrived at hospital", Nursing Daily Flowsheet dated 12/16/17 under Auxiliary Notes "Mother was informed that patient call 911 this morning".

Interview with Case Manager Director O on 12/20/17 at 11:55 AM, O confirmed s/he was aware that Patient #7 and called 911 and stated an incident report should have been filled out on this.

Interview with Quality Director B on 12/20/17 at 12:30 PM confirmed there were no incident reports regarding patient #7's call to 911 on 12/15/17.

Interview with Agency RN I on 12/18/17 at 3 PM, I stated s/he does not have access to ORS, s/he makes the charge nurse aware of incidents and it is the expectation that the charge nurse is responsible for the incident reporting.

Interview with Quality Director B on 12/20/17 at 12:30 PM confirmed if we had not received an incident report on these incidents, they were not put into the ORS.

Based on record review and interviews, the governing body failed to be responsible and accountable for the Quality Assurance and Performance Improvement (QAPI) program when it failed to be responsible for the implementation of 5 of 8 Quality Scorecard Indicators (medical records delinquency rate, falls rates, ventilator wean rate, wounds healed, and patient satisfaction).

Findings include:

Record review of Governing Board Meeting Minutes dated November 1, 2017 under Quality Reports, Recommendations/Actions revealed "Fall Program monitoring and reporting to continue... Monitor falls...Monitor Patient Satisfaction report, monitor patient rounding forms". Under Follow-up/Action Person revealed DQM/CNO [Department of Quality Management/Chief Nursing Officer].

Record review of PI Score - 2017 dated January 10, 2017 under Scorecard Report under recommendations/Actions revealed "Have Scorecard complete by the monthly meeting and be prepared to discuss any issues".

Record review of PI Score - 2017 dated February 20, 2017 under Discussion revealed "reminded the group of the importance of continual review and update of the scorecards". Nothing was noted under recommendations, actions, or follow-up.

Review of PI Score - 2017 dated April 17, 2017 under Discussion/Findings revealed " Some incomplete and possibly incorrect data". Under Recommendations/Actions "review and update scorecards prior to next meeting to ensure accuracy".

Review of Medical Executive Committee Meeting Minutes dated February 24, 2017 under Scorecard Report, Quality/Infectious Control revealed "patient falls have been an issue", under Medical Records revealed Data Quality Manager FF reported "medical records were doing well. Medical Records will continue to be monitored". No recommendations, actions or follow-up noted.

Review of Medical Executive Committee Meeting Minutes dated March 24,, 2017 under Scorecard Report revealed Data Quality Manager FF reported "patient falls have increase". Nothing is noted under recommendations/actions or follow-up.

Review of Medical Executive Committee Meeting Minutes dated April 28, 2017 under Scorecard Report revealed "Falls - 11 rate = 10.6 above desired target 3.0", no recommendations, actions or follow-up noted.

Review of Post Acute Medical Specialty Hospital of Milwaukee Medical Executive Committee Meeting Minutes for July 28, 2017 under Administrator Report: State Surveyor: revealed "some of the State citations were regarding documentation and no follow-up...CEO GG explained to the Medical Executive Committee, some of these issues should be taken care of when Electronic Medical Records is installed".

Review of Medical Executive Committee Meeting Minutes dated September 22, 2017 under Administrator Report Staffing Updates revealed "Physicians not signing, date and time on patient documentation was discussed at length. The Medical Executive Committee did review the process and made suggestions".No recommendations or follow-up actions were listed. Under Scorecard Report Quality and Infectious Control Medical Records "charts not completed within 30 days: 80% (Target, 40%)" under "Recommendations/Actions "Recommended orders and notes be tagged consistently to help increase compliance".

Review of Medical Executive Committee Meeting Minutes dated December 1, 2017 under Scorecard Report, Scorecard Review: Scorecard categories not meeting goal "Fall Rate = 5.8 with goal of 3.0. This goal has not been achieved for the past 4 months... Wounds Healed = 30% with a goal of 43%... Ventilator Wean Rate = 50% with a goal of 80%. This goal has not been achieved during 2017... Patient Satisfaction: Overall Rating = 67% with a goal of 80%. This goal has not been achieved for the past 7 months... Medical Records Delinquency Rate = 38% with a goal of 20%. This goal has not been achieved for the past 5 months" with no recommendations, actions or follow-up noted.

During interview with Director of Quality B on 12/20/2017 at 8:47 AM, B confirmed the facility has many opportunities for improvement.

Based on record review and interviews the facility failed to follow Medical Staff Bylaws and Rules and Regulations as evidenced by failing to ensure the Nurse Practitioners progress notes are co-signed by Physicians in 2 of 11 patients medical records reviewed (Patient #3 and #9).

Findings include:

Review of the Bylaws of the Medical Staff of Post Acute Specialty Hospital of Wisconsin, LLC D/B/A Post Acute Medical Specialty Hospital of Wisconsin under 5.7 Practice Privileges for Allied Health Practitioners (AHP's), 5.7.1 Scope of Practice, page 55 5.7.4-b under Dependent Practitioners revealed "Dependent AHPs are those practitioners who are subject to the general supervision and direction of a Physician while practicing in the Hospital... 2 Registered Nurse Practitioner Registered Nurse Practitioners licensed by the state may provide only those services allowed by law and approved by the Medical Staff". On page 56 under 5.7.5 Responsibility for Professional Activities revealed "If an AHP is employed by a Physician, that Physician employer retains responsibility for the professional activities of the AHP".

Review of the Post Acute Specialty Hospital Milwaukee Medical Staff Rules and Regulations titled "PAM Milwaukee Medical Staff Rules and Regulations" last reviewed July 2014 on page 13 under G. Allied Health Practitioners (AHP) 1. "Allied Health Practitioners shall have no admitting privileges and may attend patients in the Hospital only if requested by a member of the Medical Staff. The attending physician must be responsible for... the overall medical care of the patient 3. d. Write progress notes. Dependent AHPs "must obtain countersignature by supervising Medical Staff member.

Review of Patient #3's medical record on 12/19/17 revealed progress note dated 12/06/16 dictated on 12/07/16, signed by Advanced Practice Nurse Practitioner (APNP) S on 12/08/16 at 10 AM, not cosigned by physician, progress note dated 12/07/16 dictated by APNP Y on 12/08/16, signed on 12/08/16 at 7 PM, not cosigned by a physician.

Review of Patient #9's medical record on 12/20/17 revealed "Nephrology Progress Note - Dictated on behalf of " Physician MM dictated 12/12/17 9:20 AM by APNP AA, signed by APNP AA not cosigned by physician, Wound Care Consultation Report, Date of Service 12/13/17 dictated by APNP S on 12/14/17 at 9:49 PM revealed 3 blanks and signature of APNP S dated 12/18/17 at 10 AM not cosigned by a physician, progress note with date of service 12/15/17 titled "Wound Care Follow-up" dictated by APNP S on 12/15/17 at 12:39 PM, signed by APNP S on 12/18/17 at 10 AM not cosigned by a physician, Progress Note with date of service 12/15/17 titled "Nephrology Progress Note Dictated on behalf of" Physician MM dictated 12/15/17 at 10:36 AM by APNP AA, signed 12/16/17 at 9 AM, not cosigned by a physician, Progress Note dated 12/18/17 dictated 12/18/17 at 9:43 PM by APNP S not signed, dated or timed.

Interview with Chief Executive Officer C on 12/20/17 at 1:20 PM, C stated the Nurse Practitioners worked under the Medical Staff Rules and Regulations.

During interview of Medical Director D on 12/20/17 at 1:05 PM, D stated that Nurse Practitioners worked under the licenses of the Physicians who work in their clinic and confirmed that Nurse Practitioners progress notes were not co-signed by those physicians.

Based on record review and interview, the Executive Staff failed to enforce appropriate actions when making reappointments of their Medical Staff in 4 of 27 reappointments made by the Governing Board (Physicians JJ, W and V and Nurse Practitioner (NP) II).

Findings include:

Record review of the Bylaws of the Medical Staff of Post Acute Specialty Hospital of Wisconsin, LLC D/B/A Post Acute Medical Specialty Hospital of Wisconsin on page 19 under 2.6 Basic Responsibilities of Medical Staff Membership "as a condition of appointment, reappointment, and continued Medical Staff membership, each Member of the Medical Staff and each LIP [Licensed Independent Practitioner] who exercises Privileges must fulfill continuously all of the following responsibilities and obligations: 2.6.1 provide his/her patients with continuous care that meets the generally recognized professional level of quality and efficiency" page 20 under 2.6.8 "prepare and complete timely, legible, and accurate medical and other required records for all patients for whom the Practitioner in any way provides services in the Hospital" page 42 under 4.4.2. Criteria for Reappointment "The information and factors to be considered in evaluating a Member for reappointment and renewal of Privileges or granting of additional Privileges shall include, but not be limited to, the following:... 4.4.3-e sanctions of any kind imposed by any other health care institution, organization, licensing or certifying authority, or other government or law enforcement agency" Page 53 under 5.7 Practice Privileges for Allied Health Practitioners (AHPs), 5.7.3 Conditions and Duration of AHP Status, 5.73-a revealed "AHPs shall not be Members of the Hospital's Medical Staff, but shall be credentialed by the Medical Staff". Page 55 5.7.4-b under Dependent Practitioners (2) Registered Nurse Practitioner revealed "Registered Nurse Practitioners licensed by the state may provide only those services allowed by law and approved by the Medical Staff".

Record review of the Post Acute Specialty Hospital Milwaukee Medical Staff Rules and Regulations titled "PAM Milwaukee Medical Staff Rules and Regulations" last reviewed July 2014 under B. Medical Records page 6 under 8. "All clinical entries in the patient's medical record shall be legible, dated, timed, and authenticated in written or electronic form". Page 8 under C. General Conduct of Care 3. "All verbal orders shall be authenticated , by the prescribing member of the medical staff... in writing within 48 hours of receipt". Under G. Allied Health Practitioners (AHP) w. General privileges of the AHP may include the following d. "Write progress notes. Dependent AHP's (as defined by the Medical Staff Bylaws) must obtain countersignature by supervising Medical Staff member".

Record review of Post Acute Medical policy titled "Ongoing and Focused Professional Practice Evaluation" on 12/20/17 #MS13 effective date January 1, 2007, reviewed June 1, 2017 under Purpose and Scope "The organized medical staff has a leadership role in the organizations' performance Improvement activities. When the performance of a process is dependent on activities of one or more individuals with clinical privileges, the Medical Staff provides leadership for the process measurement, assessment and improvement activities. These processes include... use of information regarding adverse privileging decisions for any practitioner privileged through the Medical Staff/Allied Health process... Medical Records review for timely, accurate and legible entries... The emphasis of Performance Improvement is the Evaluation and Improvement of Processes and Outcomes. The Medical Executive Committee has the responsibility to ensure Performance/Quality Improvement and Ongoing/Focused Professional Practice Evaluations are perused"

Record review of Governing Board Meeting Minutes dated October 27, 2016 under Credentialing and Privileging Reappointments: "Physician W".

Record review of Governing Board Meeting Minutes dated November 1, 2017 under Credentialing and Privileging Credentials Committee (April through September) revealed Chief Executive Officer (CEO) C reported "we received an IJ [Immediate Jeopardy] due to lack of fit testing of providers. Except for the providers listed below, all providers have been fit tested. After numerous contacts, the following providers have not met the annual fit testing requirement. The CEO informed the committee that they have been placed on suspension until the fit testing requirement has been met" with Physician JJ and Nurse Practitioner (NP) II listed. Physician JJ, Physician V are listed under Reappointments and under Recommendations/Actions states Reappointments approved.

Record review of Governing Board Meeting Minutes dated March 2, 2017 under Credentialing and Privileging revealed Chief Executive Officer (CEO) HH updated group on Reappointments, NP II was listed as a reappointment, under recommendations "Credentialing approved - no recommendations".

Record review of Post Acute Medical Specialty Hospital of Milwaukee Medical Executive Committee Meeting Minutes for December 1, 2017 under Executive Session: FPPE/OPPE Six month review period - May 1, 2017 - November 30, 2017 "0779: Attending. status is active. For the fourteen telephone orders reviewed, the provider had a 79% unsatisfactory rate. For the five H&P {History and Physicals] and discharge summaries reviewed, the provider had a 60% delinquency rate... 4085: Palliative Care, Pain Management. Status is consulting. For the six telephone orders reviewed, the provider had a 67% unsatisfactory rate. Of the five consult notes evaluated, the provider only had one that was signed late for a 20% unsatisfactory rate. No other issues were identified... Credentialing...The credentialing report was forwarded to the Governing Board and was approved".

Record Review of Post Acute Medical Specialty Hospital of Milwaukee Quality Assessment and Performance Improvement Committee (QAPI) Meeting Minutes dated October 24, 2017 under Scorecard Review Medical Records Delinquency Rate = 40%... This goal has not been achieved for the past 5 months".

Review of Patient # 3's medical record revealed a History and Physical dictated on 12/02/16 at 10:48 PM, transcribed on 12/03/2016, signed by Physician W on 12/05/16 at 1 PM without allergies listed, a Cardiology Consultation dictated by Physician V on 12/06/2016 at 8 PM with a blanks left under allergies # 1 and #6 that is not timed or dated. Post Acute Medical Medication Reconciliation Physician Order and Patient Discharge Instructions sheet with Physician W's name written in, VORB [verbal order with read back] checked, Date of 12/02/16 time 9:30 PM written in and Physician Signature line left blank on pages 1 and 2. Progress Note dated 12/06/2016 dictated by NP S on 12/07/2016 at 3:05 PM, with signature of NP S dated 12/08/16 at 10 AM, not co-signed by a physician. Progress Note dated 12/07/2016 dictated by APNP Y on 12/08/2016 at 5:03 AM signed by APNP Y on 12/08/2016 at 7 PM without a co-signature. Consultation Report dictated by Physician X on 12/08/2016 at 7:07 PM, signed 1/04/2017 at 4:30 PM. Discharge Summary dictated 12/10/2016 at 9:45 AM by Physician W was not signed, timed, or dated.

During interview of Medical Director D on 12/20/17 at 1:05 PM, D confirmed that he was the Medical Director but stated Physician NN was the head of the Medical Executive team.

Based on record review and interview, this hospital failed to provide wound treatment as ordered by the physician to 3 of 6 patients with wounds (Patient # 1, #3 and #9).

Findings include

Record record of Policy titled Wound Care Assessment #NSG 56 effective date April 2015, reviewed April 2017 revealed under Ongoing Assessment "All wounds will be assessed daily".

Review of Patient # 1's medical record revealed Patient #1 was admitted 11/11/16, expired 12/10/16. Treatment Record dated 11/11/16 through 11/16/16 revealed treatment written in two rows, Both Buttocks, Both Forearms. Column titled Mon 11/14/16 is blank, column titled Tue 11/15/16 is blank for forearm treatments. Treatment Record dated 11/17/16 through 11/23/16 revealed treatment for Right forearm and Bilateral forearms - Columns titled Sat 11/19, Tues 11/22 and Wed 11/23 were blank.

Review of Patient #3's medical record revealed Patient # 3 was admitted 12/02/16, discharged 12/08/16, Treatment Record revealed treatment written in for sacral area and left calf, columns titled "Sat" 12/3 "Sun" were blank.

Review of Patient #9's medical record revealed Patient #9 was admitted 12/08/17 and expired 12/18/17. Treatment Record dated 12/14/17 through 12/20/17 revealed treatment written in for Left Extremity, column titled "Sat" 12/16/17 blank.

Interview during observation of wound care on 12/18/17 at 10:08 AM with Wound Care Certified Registered Nurse (RN) E, E stated wound care treatments are "documented on the TAR's" (Treatment Record), Monday through Friday the wound care RN's complete the wound care, and floor RN's do the treatments on the weekends. E confirmed if the treatments were not signed off in the Treatment Records, they were not done.

Based on observation, record review, and interviews respiratory staff failed to document reassessments per facility policy in 5 of 9 patients on a ventilator. (Patient #1, #4, #6, #8 and #12).

Findings include:

Review of the 5 page policy titled "Guidelines Respiratory Care Routine Responsibilities" dated November 2017 under All Shifts revealed "Perform ventilator checks every 2 hours".

Review of the 1 page policy titled ""Guidelines Respiratory Care Routine Responsibilities" dated November 2017 revealed "All respiratory therapy practitioners will perform ventilator checks every two hours. All respiratory therapy practitioners will perform BiPap (bilevel positive airway pressure) or CPap (continuous positive airway pressure) checks every four hours".

During observation of a small volume respiratory (SVN) treatment on 12/19/17 at 2:05 PM with Respiratory Therapist (RT) K, K stated the daily Respiratory Ventilator Flowsheets were kept with the RT during their shift, documented on at least every 4 hours or more if the patient is having issues, and added to the complete chart at the end of their shift.

Review of Patient #1's Medical Record revealed Patient #1 to be on BiPap. BiPap checks recorded in the Respiratory Ventilator Flowsheets row titled "Time" revealed consecutive times on 11/15/16 of 12:15 PM and 9:40 PM one 4 hour check late, 11/16/16 12:20 PM, 5 PM, one 4 hour check late, 11/19/16 7:30 PM through 11/20/16 12:15 AM 4:58 PM, 9:30 PM, three 4 hour checks late, 11/21/16 8:30 AM, 1 PM, 5 PM, 11:22 PM, two 4 hour checks late, 11/23/16 6:30 AM, 7:30 PM, 11:45 PM, two 4 hour checks late, 11/24/16 7:15 AM, 11:45 AM, 4:10 PM, 8:15 PM, three 4 hour checks late, 12/02/16 10:15 PM through 12/03/17 4:20 PM one 4 hour check late.

Review of Patient #4's Medical Record revealed Patient #4 to be on BiPap. BiPap checks recorded in the Respiratory Ventilator Flowsheets row titled "Time" revealed consecutive times on 12/12/17 7:20 AM, 12:10 PM, one 4 hour check late.

Review of Patient #6's Medical Record revealed Patient #6 to be on BiPap. BiPap checks recorded in the Respiratory Ventilator Flowsheets row titled "Time" revealed consecutive times on 12/17/17 7:10 AM, 11:55 AM, one 4 hour check late.

Review of Patient #8's Medical Record on 12/19/17 revealed Patient #8 to be on BiPap. BiPap checks recorded in the Respiratory Ventilator Flowsheets row titled "Time" revealed consecutive times on 12/13/17 1:15 PM, 6:10 PM, one 4 hour check late, 12/18/17 of 2 PM, 8 PM, one 4 hour check late.

Review of Patient #12's Medical Record revealed Patient #12 to be on BiPap. BiPap checks recorded in the Respiratory Ventilator Flowsheets row titled "Time" revealed consecutive times on 11/30/16 3:20 AM, 8 AM, one 4 hour check late, 12/02/16 5:30 PM, 11:40 PM, one 4 hour check late, 12/04/16 11:50 AM, 4:35 PM, one 4 hour check late, 12/07/16 5:45 AM, 10:50 AM, one 4 hour check late, 12/08/16 5:20 PM, 11:30 PM, one 4 hour check late, 12/09/16 8:50 AM, 1:03 PM, one 4 hour check late, 12/12/16 1:35 PM, 6:15 PM, 11:55 PM, two 4 hour checks late, 12/13/16 1:20 AM, 5:25 AM, 9:45 AM, 1:55 PM,three 4 hour checks late, 12/15/16 5:20 AM, 11:15 AM, 1:35 PM, 5:55 PM, two 4 hour checks late, 12/20/16 5:30 AM, 10:45 AM, one 4 hour check late.

Interview with Supervisor of Respiratory Care Q and Respiratory Manager R on 12/19/17 at 9:55 AM, Q stated that BiPap ventilators were noninvasive breathing ventilators what provide positive airway pressure, were checked every four hours, and ventilator checks were documented on the Respiratory Ventilator Flowsheet. R confirmed ventilator checks were documented on the Respiratory Ventilator Flowsheet if they were done.