HospitalInspections.org

Based on document review, hospital policy review, medical record review and interview, the hospital failed to ensure Licensed Practical Nurses (LPN) practiced within the Scope of Practice when LPN #1 administered moderate sedation medications via intravenous (IV) push to 3 of 4 (Patient #1, 2, 3) sampled patients reviewed for surgical procedures.

The findings included:

1. Review of the document RULES OF THE TENNESSEE BOARD OF NURSING CHAPTER 1000-02 RULES AND REGULATIONS OF LICENSED PRACTICAL NURSES...1000-02-.15 SCOPE OF PRACTICE documented, "...Intravenous (IV) Push Medications - The administration of intravenous push medications refers to medications administered from a syringe directly into an ongoing intravenous infusion or into a saline or heparin lock...Licensed Practical Nurses shall not administer the following fluids/medication/agents or drug classifications in the context of intravenous therapy...Moderate sedation...Anesthetics..."

2. Review of the document titled The Drug Summary for Midazolam Hydrochloride (Versed). Retrieved from a physician desk reference (PDR), 2018, http://www.pdr.net documented, "...CLASSES Anxiolytics Benzodiazepine Sedative/Hypnotics Other General Anesthetics...Administration of midazolam requires an experienced clinician trained in the use of resuscitative equipment and skilled in airway management...Monitor patients for early signs of respiratory insufficiency, respiratory depression, hypoventilation, airway obstruction, or apnea (i.e., via pulse oximetry), which may lead to hypoxia and/or cardiac arrest."

3. Review of the document titled The Drug Summary for Fentanyl Citrate. Retrieved from a physician desk reference (PDR), 2018, http://www.pdr.net documented, "...CLASSES Opiate Anesthetics...Intravenous fentanyl should only be administered by health care professionals trained in anesthesiology who are familiar with the respiratory effects of potent opioids. In addition, use of anesthetic doses of IV fentanyl requires a specialized care setting where an opiate antagonist, oxygen, and controlled respiration facilities are present..."

4. Review of the hospital's Moderate (Conscious) Sedation policy documented, "...Intravenous administration of sedative agents may be given by the physician or registered nurse as ordered by the physician..."
This policy listed Versed (Midazolam Hydrochloride) as a moderate sedation medication on Appendix E.

5. Medical record review for Patient #1 revealed the patient was admitted to the West Tennessee Surgery Center (WTSC) on 9/13/18 for same day surgery for a Left Shoulder Diagnostic Arthroscopy.

The record revealed LPN #1 administered Fentanyl 100 mcg (micrograms) IV push, and Midazolam (Versed) 2 mg (milligrams) IV push on 9/13/18 at 7:37 AM, per the physician orders.

6. Medical record review for Patient #2 revealed the patient was admitted to the WTSC on 9/20/18 for same day surgery for an Open Reduction Internal Fixation (ORIF) left wrist.

The record revealed LPN #1 administered Fentanyl 100 mcg. IV push on 9/20/18 at 7:33 AM, and Midazolam (Versed) 2 mg. IV push on 9/20/18 at 7:34 AM, per the physician orders.

7. Medical record review for Patient #3 revealed the patient was admitted to the WTSC on 9/13/18 for same day surgery for an ORIF left clavicle.

The record revealed LPN #1 administered Midazolam (Versed) 2 mg IV push on 9/13/18 at 3:53 PM, per the physician order.

Interview with the Executive Director (ED) of the WTSC and the Clinical Manager of the WTSC on 12/11/18 at 1:15 PM, in the board room, they were asked if it was acceptable for an LPN to administer moderate sedation drugs IV push. The Clinical Manager stated, "It is not normal practice for my LPN's. It is against our policy." The ED stated, "We were not aware of her doing these. It got past us." The Clinical Manager stated, "...The LPN will come out and ask the nurse (Registered Nurse) available to administer the meds (medications). There is no other LPN in my area except [Named LPN #2] and she will hunt you down [to give an IV push sedation medication]..."