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Based on observation, record review and interview the CAH failed to ensure staffing was sufficient to provide patient care services as evidenced by failing to ensure an RN was assigned and immediately available to meet the needs of patients at all times by not having a RN in ICU on 3/25/2011 from 12:05 p.m. until 1:57 p.m. for 2 of 2 patients in the ICU ( #6 and #7). The hospital also failed to ensure RNs assigned nursing care to other nursing personnel in accordance with the personnel's specialized qualifications and competence by failing to ensure personnel who observed Telemetry Monitoring was qualified and trained for 2 of 2 CNAs/PCT's (Certified Nurse Assistant/Patient Care Tech) who were assigned to monitor telemetry (#S4 & S5). This resulted in CNAs being responsible for monitoring telemetry for 2 of 2 patients (#4 & 5) who resided on the Medical-Surgical unit and 2 of 2 patients in ICU (#6 &7) that required telemetry monitoring. Findings:

1. Observation of the ICU on 3/25/2011 at 12:00 p.m. revealed there were a total of 3 patients in the ICU and 3 staff members. The staff consisted of a Charge RN (S1), Licensed Practical Nurse (LPN), S2, and a PCT, S3, who was a CNA.

Further observation of the ICU on 3/25/2011 at approximately 12:05 p.m. revealed RN S1 was observed assisting ambulance attendants to prepare patient #8 to leave the ICU for a test off campus of the hospital (approximately 15-20 miles away from facility).

Interview with RN S1 at 12:10 p.m. revealed she was going with patient #8 for a test outside of the hospital and LPN #S2 and Patient Care Tech #S3 (CNA) would be available in ICU to take care of the other patients. RN S1 further stated that the Emergency Room (ER)/ICU Nurse Manager (#S4) would be available for assistance should the staff need her for anything. RN #S1 was not observed to notify the ER/ICU Nurse Manager (#S4) prior to leaving the ICU.

Interview with LPN #S2 on 3/25/11 at 12:15 p.m. revealed she was providing care for the 2 remaining patients in ICU (#6 and #7). #S2 stated both patients had diagnoses of Congestive Heart Failure (Resolving). She further stated that the ER/ICU Nurse Manager #S4 was available if needed, however; she felt comfortable with taking care of the patients and would call #S4 if she needed to. LPN, #S2 revealed the ER/ICU Nurse Manager was probably in ER but she was not sure exactly where she was located at that time.

LPN #S2 and PCT/CNA #S3 were observed in ICU from 12:10 p.m. until 1:00 p.m. and no RN was observed to enter the ICU area during the above time.

Interview with ER/ICU Manager, #S4, on 3/25/11 at 1:05 p.m. revealed she was not aware that the Charge RN (#S1) had left the building to go with patient #8. Nurse Manager , #S4 stated she was aware that patient #8 was going off-campus for an appointment and the RN(#S1) was going to accompany the patient. However, #S4 stated she was not informed when the RN left the unit and was not aware that the RN had left the building at 12:10 p.m.

Further interview, at that time, with the ER/ICU Manager, #S4, revealed that it depended on the acuity of the ICU patients as to whether an RN or LPN were the only nurse on the unit. #S4 revealed that the Charge RN was gone with the most critical patient and it was okay that LPN #S2 and PCT/CNA #S3 were in the unit with the two remaining patients. #S4 stated the LPN would call her (#S4) if they needed anything.

Review of the medical record for patient #8 reflected the patient returned to ICU accompanied by RN #S1 at 1:57 p.m.

2. Observation of the Telemetry monitor which was located in ICU for monitoring all patients on Telemetry revealed no one was monitoring the Telemetry monitor from 12:00 to 12:15 p.m. There were observed to be a total of 4 patients on telemetry during the above time (#4, #5, #6 and #7).

Two of the 4 patients (#4 and #5) were patients who resided on the Medical-Surgical unit. The ICU staff were responsible for monitoring these patients at all times due to no Telemetry monitors located on the Medical-Surgical Unit.

The PCT/CNA #S3 was observed monitoring the Telemetry monitoring system at 12:15 p.m. Interview with PCT/CNA #S3 at that time revealed she had no formal training for telemetry monitoring. She stated she was learning as she working in the unit. #S3 stated she had been working in ICU for approximately eight months and her duties included monitoring the Telemetry system.

Review of the personnel record and ACLS training records for #S3 revealed she had not been trained to monitor telemetry and she was not ACLS certified.

LPN #S2 and PCT/CNA #S3 were observed in ICU from 12:10 p.m. until 1:57 p.m. to be the only staff to provide care to patients in the unit and alternate observing the Telemetry monitors.

Further interview with the ER/ICU Nurse Manager (#S4) on 3/25/2011 revealed she was responsible for the overall functioning of the ER and ICU departments. #S4 stated she was not aware of a policy concerning who was qualified for monitoring telemetry. #S4 revealed the RNs, LPNs, Techs and Respiratory Therapists assisted with monitoring the Telemetry monitoring system. During a further interview with #S4 on 3/28/11 at approximately 11:45 a.m revealed the PCTs/CNAs were not responsible for monitoring telemetry.

During a telephone interview with PCT/CNA #S5 on 3/28/2011 at approximately 9:11 p.m. revealed she was presently the PCT/CNA working in ICU on the 7:00 p.m. to 7:00 a.m. shift. #S5 revealed her duties included watching the telemetry monitors, and she was presently watching the telemetry monitors during the telephone interview. #S5 confirmed she had not received any formal training concerning monitoring telemetry.

Further observation of ICU on 3/28/11 at approximately 2:35 p.m. revealed there were 5 patients in ICU and 2 patients on the Medical-Surgical Unit that required and was receiving telemetry monitoring. RN, S6 and LPN, S7 were observed in ICU providing care to the patients. RN, S6 was observed in the nursing station completing paper work for the new admission patient and LPN S7 was observed in a patient's room. There was no one observed watching the Telemetry monitor at that time.

Interview with RN S6 at the above time revealed they were very busy admitting a patient and completing paperwork. She confirmed there was no one watching the Telemetry monitors at that time because they were too busy.

Based on record review and interview, the Hospital failed to meet the Condition of Participation for Provision of Services as evidenced by :

An Immediate Jeopardy situation was identified on 03/30/2011 at 10:40am and reported to S13 Administrator/DON. The Immediate Jeopardy situation was a result of:

1. The hospital failed to ensure a Registered Nurse (RN) was immediately available for patient care in the Intensive Care Unit (ICU). This was evidenced by observation and record review on 3/25/2011 from 12:05 p.m. until 1:57 p.m. in which there was no RN in ICU. Observations revealed there were 2 patients (#6 and #7) in ICU. The unit was staffed during the absence of the RN by a Licensed Practical Nurse (LPN) and a Certified Nurse Assistant (CNA). The hospital policy presented to the surveyor failed to ensure the immediate availability of an RN (with no other duties than those of patient care in the ICU) at all times. (See findings cited at C-0294)

2. The hospital also failed to ensure that nursing assignments were made according to the competency level of nursing staff by assigning Certified Nursing Assistants (#S1 and #S2) who had no documented competency or training in the interpretation of Electrocardiogram (EKG) rhythms to monitor 4 of 4 patients (#4, #5, #6 and #7) who had telemetry monitoring ordered. (See findings cited at C-0294)

The Immediate Jeopardy was lifted on 4/1/2011 at 1:30 p.m. after the hospital submitted an acceptable Plan of Removal which included:

-- To place extra staff in ICU qualified to read cardiac monitors. The extra staff will be Advanced Cardiac Life Support (ACLS) certified or have had a telemetry course. The staff will be supplied by using employees of the hospital and agency staff who must verify ACLS certification prior to monitoring Telemetry.

-- The revision of the policy/procedure titled "Staffing ICU" to reflect the following:
(1) The ICU will be staffed with an RN who is Advanced Cardiac Life Support (ACLS) certified at all times. (2) The ICU may also be staffed with at least a LPN who is qualified to read cardiac monitors and/or patient tech that is qualified to read cardiac monitor. (3) When patients are in ICU, there will be a minimum of an RN and Patient Tech at all times. (4) If a patient needs to be transferred to another facility for a procedure and the patient needs an RN to accompany the patient, then the Director of Nursing or House Supervisor must be notified so that an RN can be assigned to be in ICU. (5) If there are no patients in ICU, someone who is qualified to read cardiac monitors will be assigned to watch the monitors for the telemetry patients.

-- A Telemetry monitor Tech who was terminated in layoff was reinstated on 3/31/2011
--the provision of training/education to all clinical staff regarding the revised policies and procedures.

--The implementation of quality assurance indicators to evaluate both compliance with and the effectiveness of the revised policies and procedures.

As a result of the hospital's action plan the Immediate Jeopardy was removed and the deficiency remained at Condition Level Noncompliance.

Based on observation, record review and interview the hospital failed to ensure a RN supervised and evaluated the nursing care for each patient by failing to ensure an RN was assigned and immediately available to meet the needs of patients at all times by not having a RN in ICU on 3/25/2011 from 12:05 p.m. until 1:57 p.m. for 2 of 2 patients in the ICU ( #6 and #7). The hospital also failed to ensure RNs assigned nursing care to other nursing personnel in accordance with the personnel's specialized qualifications and competence by failing to ensure personnel who observed Telemetry Monitoring was qualified and trained for 2 of 2 CNAs/PCT's (Certified Nurse Assistant/Patient Care Tech) who were assigned to monitor telemetry (#S4 & S5). This resulted in CNAs being responsible for monitoring telemetry for 2 of 2 patients (#4 & 5) who resided on the Medical-Surgical unit and 2 of 2 patients in ICU (#6 &7) that required telemetry monitoring. Findings:

1. Observation of the ICU on 3/25/2011 at 12:00 p.m. revealed there were a total of 3 patients in the ICU and 3 staff members. The staff consisted of a Charge RN (S1), Licensed Practical Nurse (LPN), S2, and a PCT, S3, who was a CNA.

Further observation of the ICU on 3/25/2011 at approximately 12:05 p.m. revealed RN S1 was observed assisting ambulance attendants to prepare patient #8 to leave the ICU for a test off campus of the hospital (approximately 15-20 miles away from facility).

Interview with RN S1 at 12:10 p.m. revealed she was going with patient #8 for a test outside of the hospital and LPN #S2 and Patient Care Tech #S3 (CNA) would be available in ICU to take care of the other patients. RN S1 further stated that the Emergency Room (ER)/ICU Nurse Manager (#S4) would be available for assistance should the staff need her for anything. RN #S1 was not observed to notify the ER/ICU Nurse Manager (#S4) prior to leaving the ICU.

Interview with LPN #S2 on 3/25/11 at 12:15 p.m. revealed she was providing care for the 2 remaining patients in ICU (#6 and #7). #S2 stated both patients had diagnoses of Congestive Heart Failure (Resolving). She further stated that the ER/ICU Nurse Manager #S4 was available if needed, however; she felt comfortable with taking care of the patients and would call #S4 if she needed to. LPN, #S2 revealed the ER/ICU Nurse Manager was probably in ER but she was not sure exactly where she was located at that time.

LPN #S2 and PCT/CNA #S3 were observed in ICU from 12:10 p.m. until 1:00 p.m. and no RN was observed to enter the ICU area during the above time.

Interview with ER/ICU Manager, #S4, on 3/25/11 at 1:05 p.m. revealed she was not aware that the Charge RN (#S1) had left the building to go with patient #8. Nurse Manager , #S4 stated she was aware that patient #8 was going off-campus for an appointment and the RN(#S1) was going to accompany the patient. However, #S4 stated she was not informed when the RN left the unit and was not aware that the RN had left the building at 12:10 p.m.

Further interview, at that time, with the ER/ICU Manager, #S4, revealed that it depended on the acuity of the ICU patients as to whether an RN or LPN were the only nurse on the unit. #S4 revealed that the Charge RN was gone with the most critical patient and it was okay that LPN #S2 and PCT/CNA #S3 were in the unit with the two remaining patients. #S4 stated the LPN would call her (#S4) if they needed anything.

Review of the medical record for patient #8 reflected the patient returned to ICU accompanied by RN #S1 at 1:57 p.m.

2. Observation of the Telemetry monitor which was located in ICU for monitoring all patients on Telemetry revealed no one was monitoring the Telemetry monitor from 12:00 to 12:15 p.m. There were observed to be a total of 4 patients on telemetry during the above time (#4, #5, #6 and #7).

Two of the 4 patients (#4 and #5) were patients who resided on the Medical-Surgical unit. The ICU staff were responsible for monitoring these patients at all times due to no Telemetry monitors located on the Medical-Surgical Unit.

The PCT/CNA #S3 was observed monitoring the Telemetry monitoring system at 12:15 p.m. Interview with PCT/CNA #S3 at that time revealed she had no formal training for telemetry monitoring. She stated she was learning as she working in the unit. #S3 stated she had been working in ICU for approximately eight months and her duties included monitoring the Telemetry system.

Review of the personnel record and ACLS training records for #S3 revealed she had not been trained to monitor telemetry and she was not ACLS certified.

LPN #S2 and PCT/CNA #S3 were observed in ICU from 12:10 p.m. until 1:57 p.m. to be the only staff to provide care to patients in the unit and alternate observing the Telemetry monitors.

Further interview with the ER/ICU Nurse Manager (#S4) on 3/25/2011 revealed she was responsible for the overall functioning of the ER and ICU departments. #S4 stated she was not aware of a policy concerning who was qualified for monitoring telemetry. #S4 revealed the RNs, LPNs, Techs and Respiratory Therapists assisted with monitoring the Telemetry monitoring system. During a further interview with #S4 on 3/28/11 at approximately 11:45 a.m revealed the PCTs/CNAs were not responsible for monitoring telemetry.

During a telephone interview with PCT/CNA #S5 on 3/28/2011 at approximately 9:11 p.m. revealed she was presently the PCT/CNA working in ICU on the 7:00 p.m. to 7:00 a.m. shift. #S5 revealed her duties included watching the telemetry monitors, and she was presently watching the telemetry monitors during the telephone interview. #S5 confirmed she had not received any formal training concerning monitoring telemetry.

Further observation of ICU on 3/28/11 at approximately 2:35 p.m. revealed there were 5 patients in ICU and 2 patients on the Medical-Surgical Unit that required and was receiving telemetry monitoring. RN, S6 and LPN, S7 were observed in ICU providing care to the patients. RN, S6 was observed in the nursing station completing paper work for the new admission patient and LPN S7 was observed in a patient's room. There was no one observed watching the Telemetry monitor at that time.

Interview with RN S6 at the above time revealed they were very busy admitting a patient and completing paperwork. She confirmed there was no one watching the Telemetry monitors at that time because they were too busy.

Based on record review and interview, the hospital failed to ensure a security system was in place to ensure the accuracy of computer entries by failing to ensure that the author of medication entries were correctly identified for 2 of 2 patients in a total sample of 14 patients (#13 & 14). Findings:

Review of the computerized medication record for patient #13 reflected that on 3/24/11 at 17:52 (5:52 p.m.)CNA S9 administered Solu-Medrol medication 60 milligrams (mg) IV push to the patient.

Review of the computerized medication record for patient #14 revealed the patient was administered Lasix medication 20 milligrams (mg) an Intravenous push (IV), by CNA S 9 at 18:56 (6:56 p.m.) on 3/24/11. There was no documentation in the record to reflect that the medications had been administered by an RN.

Interview on 3/31/11 at approximately 1:00 p.m. with S 8, Charge RN confirmed the documentation on patient #13's medication record reflected that CNA S 9 gave Solu-Medrol 60 mg IV push to patient #13, and further documentation reflected CNA S 9 gave Lasix medication IV push to patient #14. However, RN S 8 stated that the information had to be inaccurate because CNAs are not allowed to give any medications to the patients.

Further interview with Charge RN S 8, at that time revealed if any staff member with access to the medical record log into the computer, input information into the computer, and do not log off after documentation, than another staff member can come behind that person and document information into the computer under the nursing staff member's name who is presently logged in the system. RN S 8 stated that it is the responsibility of each nursing staff member, who has access to the computer system, to log off the computer when they are finish documenting on a patient. RN S 8 further stated that each nursing staff member should check to be sure they are logged in under their own name prior to documenting in the computer system.

Interview with CNA S 9 on 3/31/2010 at 2:15 p.m. revealed she worked on 3/24/11 from 7:00 a.m. until 7:00 p.m. However, she stated she did not give any medications to patients and has never given medications to patients. S8 revealed there were 2 RNs working on the shift with her and one of the RNs gave the push medications; however, she stated she must have been still logged into the computer and therefore the nurse must have documented the information under her (S 9) name.

Telephone interview with RN S10 on 3/31/11 at 2:35 p.m. revealed she gave the IV push medications to patients #13 and #14 on 3/24/11. S 10 stated she realized after documenting the information that CNA S 9 name was the name authenticated on the record but that documentation was inaccurate. RN S 10 stated she placed a note in the pharmacist box explaining the discrepancy but did not document the information in the record.

Interview with S 11, Computer Technologist Supervisor, on 3/31/11 at 3:00 p.m. revealed the computer system has been in use for approximately one year. S 11 stated the hospital has encountered the problem in the past with someone documenting under another staff member's name. S 11 stated staff had been inserviced to ensure everyone "pay attention to logging in and out" to assure they are the person logged into the system.

Interview with the pharmacist S 12 on 4/1/11 at 10:45 a.m. confirmed she had received a note from RN S 10 concerning the inaccurate documentation concerning the administration of the IV push medications, but she did not do anything with the note, because she has no way to go into the system and document the inaccuracy. Therefore S 12 stated threw the note away because it did not apply to her.