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Based on observation, interview, and record review, the facility failed to ensure:

1. A RN was available to provide care to patients in three of 27 outpatient care areas where the scope and complexity of services offered would likely require the services of a RN, resulting in the potential for patients to go without needed care, and possible injury or death; and,

2. A single individual was responsible for the operations of the hospital's outpatient services, resulting in the potential for the provision of ineffective and unsafe services.

Findings:

1a. A tour of the Del Webb Health Center, located at 78120 Wildcat Drive in Palm Desert (8.5 miles away from the hospital), was conducted on March 2, 2011, at 10:45 a.m. The facility included a clinic that provided primary care outpatient services.

During an interview with LVN 1 on March 2, 2011, at 10:55 a.m., the LVN stated the clinic was staffed with two physicians, one LVN, and one MA during their regular operating hours of Monday through Friday, 8 a.m. to 5 p.m., and the average number of patients seen each day was 16 - 20. She stated there was no RN on staff in the clinic, and the person in charge of the clinic was the, "Office Manager."

During a concurrent interview with the Office Manager and RN 1 on March 2, 2011, at 11 a.m., the RN stated she was not in the clinic every day, she was only there when she was directed to go by the VP of Quality. The Office Manager stated she was in charge of the clinic, she was not a nurse, and she did not have any clinical background. Neither the RN or the Office Manager were able to provide a schedule or other documentation showing when RN 1 had been in the clinic.

During an interview with LVN 1 on March 2, 2011, at 11:10 a.m., the LVN stated the clinic saw patients by appointment, as well as walk in patients. She stated she assisted the physicians in performing patient care and administered, "various," medications. She stated if a patient walked in with chest pain and there was no RN present, they would put the patient in a bed and call 911. She stated that situation had happened in the past.

A review of the clinic medication list on March 2, 2011, indicated the following medications were among those available for administration by the LVN:

a. Ceftriaxone injectables 250 mg, 500 mg, and 1gram vials (for treatment of an infection);

b. Epinephrine 1:1000 injectable (to treat an allergic reaction);

c. Hydroxyzine 100 mg injectable (for treatment of nausea);

d. Ketorolac 30 mg injectable (for treatment of pain);

e. Promethazine 25 mg injectable (for treatment of nausea);

f. Methylprednisolone 40 mg and 80 mg injectables (for treatment of inflammation);

g. Albuterol 2.5 mg/3 ml (inhaled medication given for treatment of SOB associated with asthma and COPD);

h. Ipratroprium 0.5 mg/2.5 ml (inhaled medication given for treatment of SOB associated with asthma and COPD);

i. Clonidine 0.1 mg tablets (for treatment of hypertension);

j. Alprazolam 0.25 mg tablets (a controlled substance used to treat anxiety);

k. Nitroglycerine 0.4 mg tablets (given under the tongue to treat chest pain, CHF [the heart cannot pump enough blood to meet the body's needs], and pulmonary hypertension [high blood pressure in the arteries that supply the lungs]. According to the 2007 Lexi-Comp Drug Information Handbook for Nursing, when a patient is administered Nitroglycerine, the cardiac status should be monitored); and,

l. Regular Insulin 100 units/ml, 10 ml vials (given SC to treat high blood sugar). The 2008 ISMP list of high alert medications (defined as drugs that bear a heightened risk of causing significant patient harm when they are used in error) includes insulin. A fax copy of the facility policy titled, "High Alert Medications," was reviewed on March 16, 2011. The policy indicated regular insulin was considered a high alert medication, and two RNs would check the dose prior to administration. There were no RNs working in the clinic.

During a tour of the Annenberg Building (on the main hospital campus) on March 2, 2011, at 4:15 p.m., RN 1 (who stated she was the RN assigned to the clinic earlier in the day) was observed in the hallway outside of the conference room on the first floor. When asked why she was not at the clinic, she stated she really worked for the quality department at the hospital, and she did not work at the clinic.

1b. A tour of the EDOC, located behind the hospital across the parking lot, was conducted on March 2, 2011, at 2:55 p.m. The building included two physician's offices where orthopedic outpatient services were provided. The office on the second floor had 28 beds, and the third floor office had 17 beds and an MRI machine. The offices treated a combined average of 400 patients each day.

During an interview with OT 1 on March 2, 2011, at 3:20 p.m., the OT stated she was in charge of the MAs and the LVN who worked in the offices. She stated the MAs and the LVN put patients in rooms, triaged phone calls, reviewed general patient information with them, and assisted the physicians and PAs in performing patient care. She stated there was no RN on staff in the clinics.

During an interview with LVN 2 on March 2, 2011, at 3:45 p.m., the LVN stated her job title was Clinical Assistant. She stated she was not giving any medications or providing any nursing care.

A review of the Clinical Assistant job description on March 3, 2011, indicated the duties for LVN 2 included writing nurse's notes, assisting the physician with procedures, performing point of care testing (bedside testing of lab results), and changing dressings. The performance evaluation signed by the OT, dated November 24, 2010, indicated LVN 2 was meeting expectations in performing these duties. The evaluation also indicated LVN 2 had received her IV certification and was expanding her role to help with MRI patients (undergoing radiology tests).

During a concurrent interview with LVN 2 and OT 1 on March 3, 2011, at 2:45 p.m., LVN 2 stated she started IVs in the MRI unit for patients who needed contrast (dye) injected for their tests. She stated she started three to 10 IVs a week, and the MRI technicians injected the contrast. LVN 2 stated if a patient had an allergic reaction to the contrast, they would call down stairs to the OPS department (on the first floor) and, "hope a RN was available."

During an interview with the MRI technician on March 3, 2011, at 2:45 p.m., the technician stated the LVN started the IVs for the contrast, and the technician injected it. She stated if they had a patient with an allergic reaction, they would call downstairs to the OPS surgery department and ask for help.

a. The record for Patient 101 was reviewed on March 3, 2011. Patient 101, a 70 year old female, had an MRI of the right foot with contrast on February 15, 2011. LVN 2 documented an IV was started in the left arm and 14 cc of contrast was given.

b. The record for Patient 102 was reviewed on March 3, 2011. Patient 102, a 72 year old female, had an MRI of the spine with contrast on February 9, 2011. LVN 2 documented an IV was started in the left arm and 14 cc of contrast was given.

c. The record for Patient 103 was reviewed on March 3, 2011. Patient 103, a 68 year old male, had an MRI of the right elbow on February 10, 2011. LVN 2 documented an IV was started in the left arm and 20 cc of contrast was given.

The emergency kit for anaphylactic (severe allergic) reactions was observed on March 3, 2011, at 3:20 p.m. The kit included Benadryl 50 mg to be given IV, Solumedrol 125 mg to be given IV, and Epinephrine 0.3 mg to be given SC (all used to treat allergic reactions).

The hospital radiology policy titled, "Allergic Reaction to Contrast or Medication," last reviewed June 2007, indicated in the hospital a RN would would act on behalf of the patient to provide appropriate assessment and intervention in the event of an allergic reaction to contrast.

The EDOC policy titled, "Contrast Reaction - Outpatient MRI - EDOC," last reviewed September 2009, indicated in the clinic the MRI technician would call 911, call the closest open pod for assistance from a PA or MD, and ask for staff support if none was available.

1c. The multi specialty outpatient clinic, located at the edge of the hospital campus (across two parking lots), was toured on March 2, 2011, at 4 p.m., accompanied by the Clinic Educator. The staffing at the clinic included two MDs (a Pulmonologist [lung specialist] and an Infectious Disease Specialist), one MA, and one LVN. The educator stated the LVN administered medications to patients if they were ordered by the physician. She stated if the staff needed a RN, they would have to call the infusion center (located in the same building) and see if one was available.

A review of the clinic medication list on March 2, 2011, indicated the following medications were available for administration by the LVN:

a. Acetylcysteine 10% (inhaled medication given for treatment of SOB associated with acute and chronic lung disease);

b. Albuterol 2.5 mg/3 ml (inhaled medication given for treatment of SOB associated with asthma and COPD);

c. Ceftriaxone injectable one gram (given IV or IM for treatment of infection);

d. Diphenhydramine injectable 50 mg (given IV or IM for treatment of an allergic reaction);

e. Epi-Pen 0.3 ml (given SC for treatment of an allergic reaction);

f. Levalbuterol 1.25mg/3 ml (inhaled medication given for treatment of SOB associated with lung disease);

g. Nitroglycerine 0.4 mg tablets and spray (given under the tongue to treat chest pain, CHF [the heart cannot pump enough blood to meet the body's needs], and pulmonary hypertension [high blood pressure in the arteries that supply the lungs]. According to the 2007 Lexi-Comp Drug Information Handbook for Nursing, when a patient is administered Nitroglycerine, the cardiac status should be monitored);

h. Prednisone 5 and 20 mg tablets (given to decrease the inflammatory response);

i. Solumedrol injectable 125 mg (given IV or IM for treatment of an allergic reaction); and,

j. Pneumonia and Tetanus Vaccines.

2. During an interview with the VP of Quality Services on March 3, 2011, at 3:20 p.m., the VP stated she used to be in charge of the outpatient services, but had moved into the quality department and no longer managed the clinics. She stated the facility had not replaced her position.