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Based on interview and record review, the facility failed to ensure the nursing staff had proper training and competency to safely provide nursing services in accordance with standards of practice and facility policy for 1 of 20 patients (Patient 1) when:

1. Registered Nurse (RN)1, RN 2, and RN 3 lacked the specialized training and competency necessary to provide safe and competent care to Patient 1 who was on peritoneal dialysis (PD, a treatment for kidney failure that uses the lining of abdomen, or belly, to filter blood);

2. RN 2 accessed Patient 1's PD catheter (a tube that extends from the skin into the abdominal cavity and peritoneal membrane to perform PD) to collect fluid sample without any training and competency; and

3. RN 2 failed to follow the facility's chain of command when she followed the Doctor's order to collect fluid sample from Patient 1's PD catheter and RN 2 was aware that she did not have the specialized training to carry out the Doctor's order.

These failures resulted in Patient 1 not receiving safe treatment and care leading to potential compromised patient outcomes.

Findings:

A review of Patient 1's "ED [Emergency Department] notes", dated 8/28/24, indicated Patient 1 had history including kidney failure and was on PD. Patient 1 came to the ED with chief complaint of abdominal pain. ED notes indicated that MD (Medical Doctor) 2 ordered "Fluid Culture w/Gram Stain [laboratory test that identifies bacteria in a fluid sample and determines the type of bacteria causing an infection]" to be collected from PD catheter on 8/28/24 at 8:46 a.m.

1. During an interview with RN 3 on 11/5/24 at 2:55 p.m., RN 3 stated that she had not received training on accessing PD catheters or collecting fluid sample from the catheters.

During an interview with Emergency Department Director (EDD) on 11/6/24 at 10:00 a.m., EDD stated that if RN's had order to obtain PD fluid sample, they cannot do it as they are not trained to do it.

During an interview with RN 1 on 11/5/24 at 2:55 p.m., RN 1 stated that " ...no official training, usually doctors do that, they draw specimen, and we assist. Doctor's draw specimen off catheters, it's a team effort ..."

During review of personnel file for RN 1, RN 2, and RN 3 with Director Human Resources (DHR) on 11/6/24 at 11:15 a.m., there was no documented evidence of competencies for dialysis care.

2. During an interview with RN 2 on 11/7/24 at 9:15 a.m., RN 2 stated, " .... yes, I collected the sample" and " No, not trained on collecting specimen..." RN 2 further stated that she asked MD 2 to do it, he said, "No, you get the specimen". RN 2 further stated that "we were too busy to ask help from charge nurse ..."

3. During a joint interview with Chief Nursing Officer (CNO) and EDD on 11/7/24 at 9:50 a.m., EDD stated that, " ...we do not get dialysis patients, we have no policy related to dialysis... Nurses are not trained, and we transfer those patients." EDD further stated that, "For chain of command, if nurses had concerns, nursing supervisor is available 24/7 [24 hours, 7 days a week], house supervisor and Charge Nurse (CN) are also available. Leadership takes calls everyday ...At that point, nurse should have gone to CN and CN could have talk to [the] Physician. If does not work, then CN could have gone to Supervisor or EDD."

A review of facility documented titled, "Job Description- Registered Nurse ER", revised 7/2021, indicated, " ...The Emergency Department Staff Nurse provides professional nursing care to patients within the Emergency department, utilizing established policies and procedures, ensuring safe and effective care ... Essential functions- Recognizes unusual conditions outside of his/her expertise and seeks guidance of coworkers or supervisors ..."

A review of a facility policy titled, " Chain of Command for Patients Safety/Quality of Care Concerns" approved 5/25/22, indicated, "Purpose: To establish an organized process and procedure to address concerns related to patient care ...Any employee who identifies a problem with regard to patient care and is unable to reconcile it with the attending physician or nurse supervisor/manager/director should present the issue to successively higher levels of authority within the organization's chain of command until a satisfactory resolution is achieved ...Policy: [The Hospital] is committed to providing safe, quality patient care and to the timely resolution of quality of care and patient safety/potential harm concerns. All staff are responsible for ensuring that patients receive quality care at all times and should implement the chain of command procedure to address issues where quality of care or safety/harm of a patient is at question ..."