HospitalInspections.org

Based on record review, staff interviews and personnel file reviews, the hospital failed to ensure that patients received care in an environment that a reasonable person would consider to be safe relative to unlicensed personnel performing tasks outside of their scope of practice.

Findings are as follows:

1. The hospital allowed unlicensed personnel (a Certified Medical Assistant with a phlebotomy certificate) to insert intravenous (IV) catheters outside of their scope of practice in the state of Rhode Island, (Refer to A-0144).

Based on record review, staff interviews and personnel file reviews, the hospital failed to ensure that patients received care in an environment that a reasonable person would consider to be safe by allowing unlicensed personnel (a Certified Medical Assistant with a phlebotomy certificate) to insert intravenous (IV) catheters, a flexible tube inserted into a vein to deliver medications, fluids, or nutrition directly into the bloodstream, for 3 of 3 patients reviewed, (Patient ID #s 1, 2, and 3).

Findings are as follows:

On 6/13/2025, the Rhode Island Department of Health received an anonymous complaint alleging that Employee A, a phlebotomist, was observed inserting an intravenous catheter into a male patient in the Electroconvulsive Therapy (ECT) Department, a location in which ECT treatment is provided that involves electrical stimulation of the brain to treat severe mental health conditions.

The hospital's policy titled, "ECT Policies and Procedures" effective 5/3/2023 states in part,
" ...a. Anesthetics and medications are administered during treatment via intravenous (IV) line inserted by a registered nurse ..."

Record review of Employee A's personnel file revealed the employee obtained certification from the National Healthcareer Association as a Phlebotomy Technician, a healthcare professional responsible for collecting blood samples from patients, and a Clinical Medical Assistant, a healthcare worker who performs routine administrative, clerical, and clinical duties in various healthcare settings.

According to the Rhode Island Department of Health website, Medical Assistants are unlicensed healthcare workers and "must not" insert an intravenous catheter.

During a surveyor interview on 6/17/2025 at 11:15 AM with Employee A, she confirmed that she has inserted IV catheters into patients while working in the ECT Department. She revealed that if there were many patients scheduled to receive ECT, she was asked by the nurses to assist in inserting IV catheters. She revealed that since working in the ECT Department, Patient ID #s 1, 2, and 3 specifically asked for her to insert their IV catheters. When asked if she had reviewed her scope of practice on the state of Rhode Island website, she stated she did not.

During a surveyor interview on 6/16/2025 at 9:18 AM and at 2:25 PM with the Director of Nursing Education, she confirmed that Employee A has been inserting IV catheters while in the ECT Department and has personally observed her performing this task approximately 10 times. She informed the surveyor that according to an article published by an accredited Medical Assistant certification program, Medical Assistants can place IV catheters in the state of Rhode Island. When asked if she confirmed this with the Rhode Island Department of Health website, she indicated she had not. When asked if the procedure record for Patient ID #s 1, 2, and 3, indicated whether Employee A or any other staff inserted an IV catheter into the patient, she confirmed that it did not and only the site where the IV was placed is documented.