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Based on interview, record review, and review of facility policy, it was determined the facility failed to follow standard nursing practice/facility policy when the RN conducted a rectal temperature on a small child (Patient #1) while the child was standing on the bed/stretcher. The RN stated in interview that the child jumped toward the mother causing the thermometer probe to release. As a result, an unnecessary rectal exam was conducted on the child to search for the thermometer probe inside the child's rectum. The thermometer probe was later found lying on the floor.

The findings include:

Review of facility policies revealed the Emergency Department policy (undated) titled "guideline for vital signs and reassessment" failed to include guidelines/procedures for conducting rectal temperatures on pediatrics. However, the facility did have a hospitalwide policy (undated) titled "vital signs assessment, pediatrics" which was available online to staff hospitalwide. According to facility policy, staff was to obtain pediatric rectal temperatures by removing diaper, grasping infant's ankles firmly, placing the index finger between ankle bones to prevent trauma, lubricating thermometer with water soluble jelly, placing the tip of thermometer in the anus and holding in place until thermometer reading was obtained, and then discard disposable thermometer cover.

Review of the Emergency Room medical record revealed Patient #1 presented to the Emergency Room on 11/28/12, at 7:44 PM, accompanied by the mother who stated the child had a high temperature. Further review of the medical record revealed the child was assessed to have a temperature of 101.9 rectal. The diagnosis included Fever of unknown origin with discharge instructions to follow up with the primary care physician in two days.

Review of the complaints/incident log revealed the facility received a complaint via telephone from Patient #1's mother on 11/29/12. The mother reported she brought her four-year-old child to the Emergency Department on 11/28/12, for complaints of fever. The mother reported when the nurse took a rectal temperature the nurse said the probe cover had been lost inside the child's rectum. According to the mother, the nurse bent the child over and tried to locate the probe digitally and then came back with two other staff members that used a speculum to open the child's rectum and look for the probe cover. The mother stated the lubricated probe cover was found on the floor and had not been left inside the child's rectum. The mother further stated the child "went through all this" for no reason and when the mother returned home the child would not allow her to take off the child's clothes to bathe because the child had been traumatized by what happened in the Emergency Room.

A telephone interview was conducted with the RN on 12/11/12, at 3:45 PM. The RN stated Patient #1 stood on the stretcher/bed while the RN pulled the child's pants down and inserted the temperature probe inside the child's rectum. The RN stated the child jumped and the temperature probe cover popped. According to the RN, the probe cover could not be found so it was assumed the probe cover was inside the child's rectum. The RN stated she lubricated her finger and checked digitally along the outer surface of the rectum but was unable to palpate the probe. The RN then reported the incident to the Advance Registered Nurse Practitioner (ARNP) and Emergency Room Physician. The RN stated the ARNP used a nasal speculum to spread the anus/rectal canal to look inside the child's rectum while the mother held the child. The RN stated the visual inspection only lasted a few seconds and the probe was not visible inside the child's rectum. The RN stated she had been trained to take rectal temperatures on children in a lying position and did not think about the child jumping when she took the temperature from a standing position.

The ARNP working at the time of the incident stated in interview on 12/11/12, at 6:00 PM, that the RN reported the temperature probe cover was lost inside Patient #1's rectum. The ARNP gave no explanation why the child's temperature was taken from a standing position. The ARNP confirmed that the nasal speculum was inserted inside the child's rectum by the ARNP to open the anus entry in an attempt to see if the probe cover could be seen from the anal entrance. The ARNP stated the child was upset and instructions were given to the mom to lay the child across a pillow on the child's abdomen. The ARNP stated a nasal speculum was inserted approximately one inch inside the child's rectum but no foreign body was found.

The Emergency Room (ER) Physician stated in interview on 12/11/12, at 6:15 PM, that he was not present in the room when the ARNP conducted the rectal exam and did not know the rectal exam had been conducted. The ER physician stated the ARNP was qualified to conduct rectal exams, however, the ER Physician added, "I would not have conducted the rectal exam." The ER Physician gave no explanation why the child's temperature was taken from a standing position.