HospitalInspections.org

Based on interview and record review the facility failed to ensure staff RNs (Registered Nurses who are not Certified Registered Nurse Anesthetists or Advanced Nurse Practitioners) who administered sedating medications had completed competencies for conscious/procedural sedation. In addition, the facility failed to develop physician-approved policies and protocols and a risk management/quality improvement plan for administration of procedural sedation by staff RNs. This placed all patients undergoing procedures, who receive sedation by staff RNs, at risk for complications associated with procedural sedation. Findings:

Record review on 4/26-27/11 revealed 12 patients listed on the Endoscopy Tracking record for 2011, from 2/28/11 through 3/29/11. (An endoscopy is a procedure where a flexible, tube-like, telescopic instrument with a tiny camera incorporated in its tip, is used to examine images of the upper digestive tract and colon, which are displayed on a monitor; instruments may also be passed through the tube to treat certain disorders or to perform biopsies.)

Review of these 12 records revealed 10 patients had colonoscopies (examination of the colon) and 2 patients had EGDs (esophagogastroduodenoscopy, or examination of the upper digestive tract). Staff RN #1 administered the sedation for 7 patients' endoscopy procedures and Staff RN #2 administered the sedation for 5 patients' procedures. The medications Versed and Fentanyl were used for sedation in all 12 procedures.

Per Lexi-Comp's Drug Information Handbook for Nursing, 8th edition:

Versed may "cause severe respiratory depression, respiratory arrest, or apnea [absence of breathing]. Use with extreme caution, particularly in noncritical care settings", "dosing must be cautiously titrated and individualized ...particularly if other CNS [Central Nervous System] depressants ...are used concurrently", and "hypotension and/or respiratory depression may occur more frequently in patients who have received narcotic analgesics";

Fentanyl, a narcotic analgesic, may cause CNS depression, and doses "should be titrated to pain relief/prevention. When using with other CNS depressants, reduce dose of one or both agents".

Review of the facility's policy "Conscious Sedation, IV", dated October 2003, which was provided by the acting Director of Nursing, revealed "Upon physician order, a qualified RN may give IV sedation". The policy did not include a definition for "qualified RN".

Review of education records, provided by the acting Director of Nursing, revealed Staff RN #2 attended a 1 hour presentation by a CRNA on "Use of IV [intravenous] Sedation " on 2/7/07, and Staff RN #s 1 and 2 attended a 3 hour and 45 minute video conference titled "Culture of Safety: Conscious Sedation" on 8/15/09. The video conference course evaluation comments included "We need the 8 hr class and talk more specifically about pharmacology and response", "Would have liked to just hear lecture regarding AK scope of practice for RNs only (Don't care what Florida does)", and "Thought it would be more RN specific".

Review of the Alaska Board of Nursing's Advisory Opinion titled "Registered Nurse Administration of Sedating and Anesthetic Agents", dated 10/30/09, revealed "an advisory opinion is an official opinion [published by] the Alaska Board of Nursing regarding the practice of nursing as it relates to the health and safety of the Alaska healthcare consumer". Further review revealed the following:

The administration of pharmacologic agents for sedation by a specifically trained Registered Nurse, other than a Certified Registered Nurse Anesthetist (CRNA) or appropriately credentialed Advanced Nurse Practitioner, requires additional education and specific competency on the part of the Registered Nurse. One level of sedation can quickly change to a deeper level of sedation due to the unique characteristics of the drugs used, as well as the physical status and drug sensitivities of the individual patient. The administration of sedating agents requires ongoing assessment and monitoring of the patient and the ability to respond immediately to deviations from the norm, and

Any Registered Nurse who is going to administer sedating or anesthetic agents for the purposes expressed in this policy guideline has the responsibility to ensure that the following requirements are met prior to participating in moderate procedural sedation:

1. Written policies and protocols, which are readily available and are medically approved. These policies and protocols should also be consistent with current practice and include (but are not limited to) information on patient selection criteria, patient monitoring, definitions of levels of sedation, immediate availability of physician, appropriately credentialed Advanced Nurse Practitioner and CRNA (if applicable), drug administration and directions for dealing with potential complications or emergency situations; and

2. Written risk management and quality improvement plan in place.

3. The immediate availability of the appropriately credentialed LIP (Licensed Independent Practitioner) capable of advanced airway maintenance.

4. The LIP managing the procedure is properly credentialed by the facility in the use of the moderate procedural sedation/anesthetic agents.

Based on record review and interview the critical access hospital failed to conduct an annual review and evaluation of all hospital services. As a result, there was no documented evidence of an annual evaluation that included determining appropriateness of utilization of services, a sample of active and closed clinical records, adherence to facility policies and procedures, and changes in facility practices. Without sufficiently identifying or adequately addressing and communicating about areas of deficient practice, systematic corrections cannot be achieved and maintained throughout the facility. Findings:

On 4/26/2011 the surveyors asked the Director of Development and Quality for the hospital's written annual review and evaluation. Review of the annual evaluation included: "Purpose of Review: To determine if utilization of services were appropriate to meet the community needs, To determine compliance with established policies and procedures, and Identify changes, if needed, in the program services or policies."

The Section entitled "Utilization of Hospital Services for FYE-2008" included the annual average length of stay; total patient acute days and a comparison to the previous year, total patient swing bed days, and stays greater than 4 days for acute care patients. An evaluation of the utilization of services was not documented.

Under the heading "Review of Patient Care Services" the following services were included: Laboratory; Emergency Department; Dietary Services; Rehabilitation Services; Imaging; Pharmacy; Quality Department; Health Information Management; Information Technology (IT) Services; Acute Care Services; Long Term Care; Specialty Care Services; and Maintenance Department. Each service included a description of what each department did and/or the services offered under each department (ex: emergency department (ER) - registered nurse on duty 24 hours a day; dietary - offers appetizing nutritious foods prepared and served under sanitary conditions and at appropriate temperatures; rehabilitation - full service inpatient, outpatient and home health physical therapy; imaging - offers mammograms, xray, and ultrasound activities; pharmacy - well stocked drug room for ER and inpatient use; quality department - monthly report of QA activities, began a plan to improve QA, QI, and PI program at WMC). There was no evaluation/analysis of the services; a sample of active and closed records was not included as part of the review, and there was no documentation of a review of facility policies and procedures.

The CAH Annual Program Review was signed on 12/16/2008 by the Chief Executive Officer; President of the Board of Directors; Chief of Staff; Director of Quality, Quality Committee; and a Community Member Liaison.

During an interview on 4/26/2011 at 11:10 am with the Director of Quality and the Acting Director of Nursing, they confirmed 2008 was the only annual review completed and the 2008 annual review was a description of services offered, not an evaluation or analysis of those services or of facility policies and procedures. As a result, there was no documentation of an annual Wrangell Medical Center review for 2008, 2009, and 2010. The Director of Quality confirmed that she was responsible for conducting/coordinating the annual review.

Review on 4/27/2011 of the job description for the Director of Development and Quality revealed "Designs, implements, and performs audit, education, and review of hospital activities subject to regulatory compliance, quality assurance, and general organizational performance improvement..."

Based on record review and interview the critical access hospital failed to ensure another hospital that is a member of the network evaluated the quality and appropriateness of diagnoses and treatments furnished by the facility physicians. Failure to evaluate appropriateness of diagnoses and treatments could result in deficient practices not being identified and corrective actions not being implemented. Findings:

Review on 4/27/2011 of the hospital's Quality Assurance Program revealed a "Memorandum of Understanding Bartlett Regional Hospital Wrangell Medical Center Quality Assurance", dated 11/19/2008, and signed by the Bartlett Regional Hospital Administrator on 12/8/2008 and the Administrator of Wrangell Medical Center on 12/10/2008. The Memorandum of Agreement included "...4. WMC and BRH will exchange review criteria that might be meaningful to the review process of the other facility..." The Memorandum of Agreement did not include a provision for the network hospital to evaluate the appropriateness of diagnoses and treatments by Wrangell Medical Center physicians.

During an interview with the Director of Quality on 4/26/2011 at 9:38 am she confirmed that a review by Bartlett Hospital had not been completed and stated that Bartlett could do such a review.