HospitalInspections.org

At the time of the follow-up, this deficiency was not corrected.

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Based on review of hospital documents and medical records and interviews with hospital staff, the hospital failed to assure nursing staff are adequately trained, oriented and competent to provide care to meet the needs of the patients.

Findings:

1. Conscious/Moderate Sedation:
Ten nursing personnel files were chosen for review.

a. Although review of nursing inservice checklist on 01/26/2010 documented the ten nurses had been appropriately trained to administer moderate sedation, review of the hospital's training documents showed the nurses had not been trained on the respiratory components required by the Oklahoma Board of Nursing and that was included in the hospital's training material supplied to the surveyors by the Acting Director of Nursing on the morning of 01/26/2010.

b. The hospital's "Moderate Sedation" policy, with an effective date of 01/04/2010, stipulated that nurses (RN [registered nurse] and LPN [licensed practical nurse]) demonstrate competency in airway management and resuscitation (such as ACLS [advanced cardiac life support] or PALS [pediatric advanced life support]) appropriate to the age of the patient. Five of the ten nurses, whose personnel files were reviewed, did not have current ACLS training. This was confirmed with the human resource staff on the afternoon of 01/26/2010.

c. In two of two surgery charts (Records # 21 and 22) reviewed, of patients who were administered moderate sedation during a surgical procedure, the LPN who performed post-anesthesia recovery and the post-anesthesia evaluation did not have ACLS or moderate sedation training containing the respiratory component.

2. Nursing competencies/skills check:
Ten nursing personnel files were chosen for review. The competency- performance evaluation material contained in the personnel files were self-evaluations by each nurse. The skill competency material did not contain evidence the skills had been observed and checked. The Acting Director of Nurses stated on the afternoon of 01/26/2010, that only the self-evaluation portion of the skill competency have been completed.

3. Nursing Respiratory competency:
a. Ten of the ten nursing personnel files reviewed contained documentation they had been trained and observed for competency to administer respiratory services/treatments.

b. On interview with the respiratory therapist, she supplied documentation of training to nursing staff on respiratory services. Only one RN and all but one LPN had completed the training. This finding was confirmed with the respiratory therapist.

c. Review of two medical records (Records #10 and 12), of patients who had respiratory services, compared to the respiratory therapist competency documentation, demonstrated that one of six nursing staff who administered hand held nebulizer treatments had not been trained to administer the treatments.

4. Non-employee nursing staff:
One of one agency nursing staff, who had worked at the hospital previously and was working as charge nurse on the day of the survey and whose personnel filed was review had not been oriented to the hospital's policies and procedures and forms. The personnel file did not contain evidence the hospital had provided orientation, training or competency verification. This finding was confirmed with human resources staff and the Acting Director of Nursing on the afternoon of 01/26/2010.

Based on record review and interviews with hospital staff, the hospital does not ensure that the medical staff participates and evaluates all patient care services and other services provided by the hospital.

Findings:

1. Review of medical staff meeting minutes and Quality Assurance/Performance Improvement (QA/PI) for the previous twelve months did not have evidence of the review of morbidity and mortality, tissue, medical records or transfusions by the medical staff to evaluate appropriateness of care provided to patients.

2. Fifty-two medical records were sent by the hospital for review by Oklahoma Foundation for Medical Quality (OFMQ), but at the time of the survey the hospital had not received the result of OFMQ's review. Hospital staff stated on 01/26/10 in the afternoon that the records were randomly selected and no criteria was used to specifically evaluate morbidity and mortality, tissue, medical records or transfusions.

3. Hospital staff stated on 01/26/10 in the afternoon there were no QAPI reviews of charts of morbidity and mortality, tissue, medical records or transfusions by the medical staff to evaluate appropriateness of care provided to patients.