**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, document review, and in the course of a complaint investigation, the facility staff failed to provide respiratory therapy care and services to address the needs of four (4) of eight (8) sampled residents with ventilator orders (Resident #1, Resident #2, Resident #3, and Resident #4). For Resident #1, On [DATE] at 3:50 P.M., Immediate Jeopardy-Past Noncompliance was called, and lowered to a D. Resident #2, Resident #3, and Resident #4 were included in the Past non-compliance designation. The findings include: 1. The facility staff failed to implement Resident #1's medical provider's ventilator orders to ensure the resident was provided the necessary ventilation and oxygen. The facility staff failed to ensure Resident #1's ventilator care and/or ventilator assessments were appropriately completed by a respiratory therapist (RT). The facility staff failed to ensure Resident #1's remote ventilator alarm was turned on when the resident's ventilator was in use. (The remote ventilator alarm is a supplemental alarm used in addition to the alarms built into the ventilator. The remote alarm was located near the top of the door, in the hallway, outside Resident #1's room.) Resident #1's minimum data set (MDS) assessment, with an assessment reference date (ARD) of [DATE], was dated as completed on [DATE]. Resident #1 was assessed as able to make self understood and as able to understand others. Resident #1's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15 (indicating intact and/or borderline cognition). Resident #1 was assessed as requiring assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #1's diagnoses included Respiratory Failure. Resident #1 was documented as receiving oxygen therapy, suctioning, tracheostomy care, and invasive mechanical ventilator use. Resident #1's medical provider orders included: - Settings for ventilator use related to CHRONIC RESPIRATORY FAILURE WITH HYPOXIA dated [DATE] and - (tracheostomy collar) trials 4 (hours two times a day) and with (physical therapy) increase (oxygen) to 10 (liters) and with (Passy Muir Valve) two times a day for WEANING related to DEPENDENCE ON RESPIRATORY [VENTILATOR] STATUS dated [DATE]. The facility policy and procedure titled Passy-Muir Valve (this document was not dated) indicated its use was the basic responsibility of respiratory therapist (RT) and/or speech therapist (ST). This documented stated the purpose of the Passy-Muir Valve (PMV) is to aid in the weaning of a resident from an artificial airway and facilitate communication. The facility policy/procedure titled Ventilator Management (this document was not dated) provided the following information: All ventilators that are in a resident room will be connected to an external audible alarm. Resident #1's care plan included a focus of resident is ventilator dependent via tracheostomy secondary to respiratory failure. This care planned focus included the following interventions: administer oxygen as ordered, respiratory therapy as ordered, ventilator setting per order, and weaning protocol as indicated. On [DATE] at 1:25 p.m., the surveyor interviewed the facility's Administrator about Resident #1 being found unresponsive on the evening of [DATE]. The Administrator stated it was determined that Resident #1 was removed from the ventilator on [DATE] at 9:44 a.m. by Respiratory Therapist (RT) #2 for a weaning trial/trach collar trial. The Administrator reported RT #2 stated they had placed Resident #1 back on the ventilator on [DATE] at 6:10 p.m. The Administrator acknowledged Resident #1's weaning trial/trach collar trial and the reported return to the ventilator had not been documented. The Administrator reported, that at approximately 7:30 p.m. on [DATE], RT #1 found Resident #1 unresponsive while doing rounds. On [DATE] at 5:48 p.m., Respiratory Therapist (RT) #1 was interviewed about finding Resident #1 unresponsive on the evening of [DATE]. RT #1 confirmed they found Resident #1 unresponsive on the evening of [DATE], at approximately 7:30 P.M. RT #1 reported, when they entered Resident #1's room, they knew something was wrong. RT #1 stated they asked Resident #1 if they needed anything, but the resident did not respond. RT #1 stated Resident #1 was extremely cold. RT #1 reported Resident #1 was found connected to the ventilator, but the ventilator was in standby and wasn't providing respirations. RT #1 reported they turned the ventilator on and went to yell for help. RT #1 reported when they turned the ventilator on it appeared as if it was working properly. RT #1 reported basic life support, including the use of an automated external defibrillator (AED), was provided. RT #1 reported Resident #1 was not revived. On [DATE] at 10:10 a.m., Respiratory Therapist (RT) #2 was interviewed, via telephone, about the event referenced in this complaint. RT #2 had provided care for Resident #1 during dayshift (7AM - 7PM) on [DATE]. RT #2 reported it was a typical day. RT #2 stated Resident #2 completed the second weaning trial / trach collar trial at approximately 6:00 p.m. on [DATE]. RT #2 stated they placed Resident #2 back on the ventilator. RT #2 reported the ventilator was working; RT #2 reported Resident #1's heart rate was in the 70s and the resident's oxygen saturation was in the upper 90%. RT #2 stated they suctioned Resident #1 twice; RT #2 stated it was not deep suctioning. RT #2 reported they left Resident #2's rooms to respond to a resident calling-out from another room. When asked if they turned on the ventilator alarm located outside Resident #1's room, RT #2 stated, I believe I did not. On [DATE] at 1:37 p.m., the facility's Administrator and Director of Respiratory were asked for copies of Resident #1's ventilator machine data reports. The facility staff was able to provide a report of some of the internal data from Resident #1's ventilator. The facility staff was unable to provide guidance to explain the information retrieved from the ventilator's internal data. The data obtained from Resident #1 ventilators was reviewed for evidence of ventilator use at the following times: on [DATE] at approximately 6:10 p.m. and on [DATE] at approximately 7:30 p.m. The information provided to the surveyor from the ventilators internal data was not clear about ventilator use at the aforementioned times. Resident #1's ventilator was being sent to the manufacture for further evaluation. On [DATE] at 9:08 a.m., the surveyor reviewed Resident #1's respiratory care documentation with the facility's Director of Respiratory. The following issues were identified: - On [DATE]'s 7AM dayshift, Resident #1's respiratory documentation failed to include (a) a progress note for when the resident was placed on a weaning trial / trach collar trial and (b) a ventilator check assessment when the resident was placed back on the ventilator after the conclusion of the weaning trial / trach collar trial. The Director of Respiratory reported the facility did not have a policy and/or procedure detailing the documentation of weaning trials/trach collar trials. The Director of Respiratory reported a progress note should have been documented when the weaning trial/trach collar trial was initiated and that a ventilator check assessment should have been completed when the ventilator was restarted after the conclusion of the weaning trial/trach collar trial. - On [DATE]'s 7AM dayshift, Resident #1's respiratory documentation failed to provide evidence of a respiratory therapist providing the weaning trial/trach collar trial; documentation of the weaning trial/trach collar trial was documented by a licensed practical nurse (LPN). The Director of Respiratory reported a respiratory therapist should have provided the weaning trial/trach collar trial and a respiratory therapist should have completed a ventilator check assessment at the time the resident was placed back on the ventilator after the weaning trial/trach collar trial. - On [DATE]'s 7PM nightshift, Resident #1's respiratory administration record (RAR) indicated the resident's weaning trial/trach collar trial was not provided as ordered. The Director of Respiratory confirmed there was no documentation to indicate the weaning trial/trach collar trial had been provided. The Director of Respiratory reported a reason for not providing the weaning trial/trach collar trial had not been documented. - On [DATE]'s 7AM dayshift, Resident #1's respiratory documentation failed to include (a) a progress note for when the resident was placed on a weaning trial/trach collar trial and (b) a ventilator check assessment when the resident was placed back on the ventilator after the conclusion of the weaning trial/trach collar trial. The Director of Respiratory reported a progress note should have been documented when the weaning trial/trach collar trial was initiated and that a ventilator check assessment should have been completed when the ventilator was restarted after the conclusion of the weaning trial/trach collar trial. - On [DATE]'s 7AM dayshift, Resident #1's respiratory documentation failed to include (a) a progress note for when the resident was placed on a weaning trial/trach collar trial and (b) a ventilator check assessment when the resident was placed back on the ventilator after the conclusion of the weaning trial/trach collar trial. The Director of Respiratory reported a progress note should have been documented when the weaning trial/trach collar trial was initiated and that a ventilator check assessment should have been completed when the ventilator was restarted after the conclusion of the weaning trial/trach collar trial. - On [DATE]'s 7AM dayshift, Resident #1's respiratory documentation failed to include (a) a progress note for when the resident was placed on a weaning trial/trach collar trial and (b) a ventilator check assessment when the resident was placed back on the ventilator after the conclusion of the weaning trial/trach collar trial. The Director of Respiratory reported a progress note should have been documented when the weaning trial/trach collar trial was initiated and that a ventilator check assessment should have been completed when the ventilator was restarted after the conclusion of the weaning trial/trach collar trial. - On [DATE]'s 7PM nightshift, Resident #1's respiratory progress note, timed 7:05p.m., indicated the resident's weaning trial/trach collar trial was not provided due to both weaning trials/trach collar trials had been provided during the dayshift. The Director of Respiratory confirmed there was no documentation indicating both of the provider ordered weaning trials/trach collar trials had been provided during the dayshift. On [DATE] at 1:42 p.m., the facility's Director of Respiratory reported all respiratory staff had been in-serviced related to ventilator care or will receive in-service training prior to being allowed to work their next shift. Documentation of the respiratory staff training, dated [DATE], was provided to the surveyor prior to the conclusion of the survey. All other residents on ventilators were observed to receive oxygen per physician's order during each day of the survey. The facility staff began every 30-minute monitoring the external ventilator alarms on [DATE]. This monitoring was ongoing and was planned to be continued until reviewed by the facility's quality assurance and performance improvement (QAPI) committee. Documentation of the 30-minute external ventilator monitoring was provided to the surveyor. The facility's respiratory care department implemented mandatory walking rounds/report on [DATE]. The facility's Director of Respiratory provided the surveyor with evidence of respiratory staff communication of the mandatory walking rounds/report dated [DATE]. Interviews with current respiratory staff members confirmed walking rounds/report were occurring at change of shift. On the morning of [DATE], the facility's Administrator reported the facility's quality assurance and performance improvement (QAPI) committee will review any identified respiratory issues during the upcoming QAPI meeting. This is a complaint deficiency. 2. The facility staff failed to ensure Resident #2's ventilator assessments were completed by a respiratory therapist (RT) at the appropriate times. The Director of Respiratory, on [DATE] at 8:40 a.m., provided a copy of a document titled DAILY ROUNDS. This document indicated ventilator assessments were to be completed at least twice per 12-hour shift. Resident #2's minimum data set (MDS) assessment, with an assessment reference date (ARD) of [DATE], was dated as completed on [DATE]. Resident #2 was assessed as able to make self understood and as able to understand others. Resident #2's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15 (indicating intact and/or borderline cognition). Resident #2 was assessed as being independent with bed mobility, dressing, eating, and toilet use. Resident #2 was assessed as requiring supervision with transfers and personal hygiene. Resident #2's diagnoses included Respiratory Failure. Resident #2 was documented as receiving oxygen therapy, suctioning, tracheostomy care, and invasive mechanical ventilator use. Resident #2's medical provider orders included an order dated [DATE] for the use of a mechanical ventilator. Resident #2's care plan included a focus of (resident name omitted) is ventilator dependent via tracheostomy secondary to respiratory failure. The facility policy/procedure titled Ventilator Management (this document was not dated) provided the following information: - The policy stated it was the basic responsibility of the respiratory therapist. - Under the heading of Procedure were the following steps: 1. Verifies physician order. 2. Washes hands, maintains standard precautions. 4. [sic] Obtains appropriate supplies/equipment. 5. Identifies resident, explains procedure, and provides privacy. 6. Properly assembles supplies/equipment. 7. Perform operational check. a. If ventilator fails operational check pull from service and place defective sticker. 8. Adjust ventilator to prescribed settings. 9. Connect ventilator to resident. 10. Confirm PEEP valve set to correct setting 11. Analyze FI02. 12. Assess resident respiratory status. (HR, RR, BBS, SP02) 13. If new admission perform ETC02 analysis. 14. Document. - Under the heading of Documentation were the following items: 1. Date and time of procedure. 2. Ventilator settings. 3. Resident respiratory status. 4. Resident response to therapy 3. [sic] Signature. On [DATE] at 12:31, the facility's Administrator, ADON, and Director of Respiratory were interviewed about LPN monitoring of ventilator care and/or weaning trials/trach collar trials. It was reported that the facility did not have a written policy and/or procedure detailing LPN responsibility in monitoring ventilator care and/or weaning trials/trach collar trials. The facility's Director of Respiratory and the surveyor reviewed Resident #2's clinical documentation on the [DATE] at 9:14 a.m. It was noted that only one (1) ventilator assessment was completed for the 7AM - 7PM shift on [DATE]. Respiratory Therapist (RT) #3 was documented as completing a ventilator assessment on [DATE] at 8:08 a.m. RT #3's time clock records indicated they (RT #3) was not working at the time of the aforementioned ventilator assessment. The Director of Respiratory reported the ventilator assessment should have been completed by one of the respiratory therapists working at the time the ventilator assessment was due. The Director of Respiratory reported two (2) ventilator assessments should have been completed during the 7AM - 7PM shift on [DATE]. RT #3 was interviewed via telephone on [DATE] at 7:05 p.m. RT #3 reported, when they came in early on the afternoon of [DATE], they were instructed by other respiratory staff members to document resident information collected by a licensed practical nurse (LPN) who was working as part of the respiratory staff. RT #3 stated they documented the information collected by the LPN. RT #3 stated they contacted the Director of Respiratory, on [DATE], because they (RT #3) had been uncomfortable with documenting the information collected by the LPN. On [DATE] at 10:10 a.m., the survey team met with the facility's Administrator and Director of Respiratory. RT #3 documenting information collected by an LPN and only one (1) ventilator assessment being completed on [DATE] dayshift was discussed during this meeting. Resident #2 was included in the Past non-compliance designation. 3. The facility staff failed to ensure Resident #3's ventilator assessments were completed by a respiratory therapist (RT) at the appropriate times. The Director of Respiratory, on [DATE] at 8:40 a.m., provided a copy of a document titled DAILY ROUNDS. This document indicated ventilator assessments were to be completed at least twice per 12-hour shift. Resident #3's minimum data set (MDS) assessment, with an assessment reference date (ARD) of [DATE], was dated as completed on [DATE]. Resident #3 was assessed as able to make self understood and as able to understand others. Resident #3's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15 (indicating intact and/or borderline cognition). Resident #3 was assessed as requiring assistance with bed mobility, dressing, toilet use, and personal hygiene. Resident #3's diagnoses included Respiratory Failure. Resident #3 was documented as receiving oxygen therapy, suctioning, tracheostomy care, and invasive mechanical ventilator use. Resident #3's medical provider orders included an order dated [DATE] for the use of a mechanical ventilator. Resident #3's care plan included a focus of resident is ventilator dependent via tracheostomy secondary to respiratory failure . The facility policy/procedure titled Ventilator Management (this document was not dated) provided the following information: - The policy stated it was the basic responsibility of the respiratory therapist. - Under the heading of Procedure were the following steps: 1. Verifies physician order. 2. Washes hands, maintains standard precautions. 4. [sic] Obtains appropriate supplies/equipment. 5. Identifies resident, explains procedure, and provides privacy. 6. Properly assembles supplies/equipment. 7. Perform operational check. a. If ventilator fails operational check pull from service and place defective sticker. 8. Adjust ventilator to prescribed settings. 9. Connect ventilator to resident. 10. Confirm PEEP valve set to correct setting 11. Analyze FI02. 12. Assess resident respiratory status. (HR, RR, BBS, SP02) 13. If new admission perform ETC02 analysis. 14. Document. - Under the heading of Documentation were the following items: 1. Date and time of procedure. 2. Ventilator settings. 3. Resident respiratory status. 4. Resident response to therapy 3. [sic] Signature. On [DATE] at 12:31, the facility's Administrator, ADON, and Director of Respiratory were interviewed about LPN monitoring of ventilator care and/or weaning trials/trach collar trials. It was reported that the facility did not have a written policy and/or procedure detailing LPN responsibility in monitoring ventilator care and/or weaning trials/trach collar trials. The facility's Director of Respiratory and the surveyor reviewed Resident #3's clinical documentation on the [DATE] at 9:27 a.m. It was noted that only one (1) ventilator assessment was completed for the 7AM - 7PM shift on [DATE]. Respiratory Therapist (RT) #3 was documented as completing a ventilator assessment on [DATE] at 8:55 a.m. RT #3's time clock records indicated they (RT #3) was not working at the time of the aforementioned ventilator assessment. The Director of Respiratory reported the ventilator assessment should have been completed by one of the respiratory therapists working at the time the ventilator assessment was due. The Director of Respiratory reported two (2) ventilator assessments should have been completed during the 7AM - 7PM shift on [DATE]. RT #3 was interviewed via telephone on [DATE] at 7:05 p.m. RT #3 reported, when they came in early on the afternoon of [DATE], they were instructed by other respiratory staff members to document resident information collected by a licensed practical nurse (LPN) who was working as part of the respiratory staff. RT #3 stated they documented the information collected by the LPN. RT #3 stated they contacted the Director of Respiratory, on [DATE], because they (RT #3) had been uncomfortable with documenting the information collected by the LPN. On [DATE] at 10:10 a.m., the survey team met with the facility's Administrator and Director of Respiratory. RT #3 documenting information collected by an LPN and only one (1) ventilator assessment being completed on [DATE] dayshift was discussed during this meeting. Resident #3 was included in the Past non-compliance designation. 4. The facility staff failed to ensure Resident #4 had two (2) ventilator assessments completed on [DATE] during the dayshift (7AM - 7PM). The Director of Respiratory, on [DATE] at 8:40 a.m., provided a copy of a document titled DAILY ROUNDS. This document indicated ventilator assessments were to be completed at least twice per 12-hour shift. Resident #4's minimum data set (MDS) assessment, with an assessment reference date (ARD) of [DATE], was dated as completed on [DATE]. Resident #4 was assessed as rarely and/or never able to make self understood and as rarely and/or never able to understand others. Resident #4 was documented as having severely impaired cognitive skills for daily decision making. Resident #4 was assessed as being dependent on others for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Resident #4's diagnoses included Respiratory Failure. Resident #4 was documented as receiving oxygen therapy, suctioning, tracheostomy care, and invasive mechanical ventilator use. Resident #4's medical provider orders included an order dated [DATE] for the use of a mechanical ventilator. Resident #4's care plan included a focus of resident is ventilator dependent via tracheostomy secondary to respiratory failure. The facility policy/procedure titled Ventilator Management (this document was not dated) provided the following information: - The policy stated it was the basic responsibility of the respiratory therapist. - Under the heading of Procedure were the following steps: 1. Verifies physician order. 2. Washes hands, maintains standard precautions. 4. [sic] Obtains appropriate supplies/equipment. 5. Identifies resident, explains procedure, and provides privacy. 6. Properly assembles supplies/equipment. 7. Perform operational check. a. If ventilator fails operational check pull from service and place defective sticker. 8. Adjust ventilator to prescribed settings. 9. Connect ventilator to resident. 10. Confirm PEEP valve set to correct setting 11. Analyze FI02. 12. Assess resident respiratory status. (HR, RR, BBS, SP02) 13. If new admission perform ETC02 analysis. 14. Document. - Under the heading of Documentation were the following items: 1. Date and time of procedure. 2. Ventilator settings. 3. Resident respiratory status. 4. Resident response to therapy 3. [sic] Signature. On [DATE] at 12:31, the facility's Administrator, ADON, and Director of Respiratory were interviewed about LPN monitoring of ventilator care and/or weaning trials/trach collar trials. It was reported that the facility did not have a written policy and/or procedure detailing LPN responsibility in monitoring ventilator care and/or weaning trials/trach collar trials. The facility's Director of Respiratory and the surveyor reviewed Resident #4's clinical documentation on the [DATE] at 9:35 a.m. It was noted that no ventilator assessments were completed for the 7AM - 7PM shift on [DATE]. Respiratory Therapist (RT) #3 was documented as completing a respiratory assessment on [DATE] at 8:30 a.m. RT #3's time clock records indicated they (RT #3) was not working at the time of the aforementioned respiratory assessment. The Director of Respiratory reported two (2) ventilator assessments should have been completed during the 7AM - 7PM shift on [DATE]. RT #3 was interviewed via telephone on [DATE] at 7:05 p.m. RT #3 reported, when they came in early on the afternoon of [DATE], they were instructed by other respiratory staff members to document resident information collected by a licensed practical nurse (LPN) who was working as part of the respiratory staff. RT #3 stated they documented the information collected by the LPN. RT #3 stated they contacted the Director of Respiratory, on [DATE], because they (RT #3) had been uncomfortable with documenting the information collected by the LPN. On [DATE] at 10:10 a.m., the survey team meet with the facility's Administrator and Director of Respiratory. RT #3 documenting information collected by an LPN and no ventilator assessment being completed on [DATE] dayshift was discussed during this meeting. Resident #4 was included in the Past non-compliance designation.