Observations:
Based on review of the facility's Plan of Correction (POC), facility documents, and staff interview (EMP), it was determined Penn State Health Rehabilitation Hospital failed to follow their POC that was submitted to and accepted by the Department with a completion date of January 30, 2024
Findings include:
On March 14, 2024, a review of the facility POC revealed, The Chief Nursing Officer (CNO) reviewed Respiratory Therapy Policy 001, Oxygen Administration with the nursing staff. This review emphasized prompt physician notification when oxygen saturation levels cannot be maintained as ordered. Education will be completed on January 25, 2024. As of January 26, 2024, any nursing staff that has not completed this education, will do so prior to working their next scheduled shift.
Review of the facility's documentation revealed that staff training of the Respiratory Therapy Policy 001, Oxygen Administration was not completed.
Interview with EMP1 on March 20, 2024, via telephone confirmed that the Respiratory Therapy Policy 001, Oxygen Administration training was not completed.
| | Plan of Correction - To be completed: 04/08/2024
The Chief Nursing Officer (CNO) and the Director of Quality Management (DQM) reviewed the Plan of Correction (POC) deficiency of 101.111 on 3/18/2024. This examination identified that the education provided to the staff did not include the entire Respiratory Therapy Policy 001, Oxygen Administration.
On 3/20/2024, the CNO and the DQM developed Power Point education slides that explicitly include Respiratory Therapy Policy 001, Oxygen Administration, with emphasis on prompt physician notification when oxygen saturation levels cannot be maintained as ordered. The entire policy was reviewed during three staff meetings which were all held on 3/20/24 and staff attendance was documented. The entire policy will also be reviewed during the twice a day shift huddles for the next 2 weeks and during scheduled staff meetings. Education will be completed by April 8. Any nursing staff that has not completed this education by April 8 will do so prior to starting their next scheduled shift. Staff policy review acknowledgment will be attached to the Respiratory Therapy Policy 001, Oxygen Administration.
Compliance with the above plan will be monitored by the CNO, or designee, by auditing each education list for staff names and policy attachment. This will continue until compliance has been achieved. At that time, findings will be reported to the monthly Quality Assurance Process Improvement (QAPI) Team and quarterly to the Quality and Patient Safety Committee, Medical Executive Committee (MEC) and Governing Board (GB).
The CNO is ultimately responsible for ensuring the plan of correction is implemented and that compliance is achieved and maintained.
|
