HospitalInspections.org

Based on interviews and the review of documentation, it was determined the hospital failed to ensure that nursing services were provided by qualified personnel trained to meet the individualized care needs of the patients.

Findings:

The review of documentation in closed surgical records revealed 3 of 7 records (Records 1, 2, and 3) revealed that unqualified personnel had provided care to these patients.

Record 1: Review of documentation revealed Patient 1 was admitted on 2/23/2016 from the ED with a diagnosis of acute cholecystitis. Documentation revealed Patient 1 had a laparoscopic cholecystectomy on 2/24/2016.

Review of documentation on the intraoperative nursing record for Patient 1, dated 2/24/2016, identified personnel in the OR during Patient 1's procedure included a circulating RN, scrub personnel, a surgical assistant, a CRNA, and the surgeon. Review of documentation on the anesthesia report for this procedure identified additional personnel as being present in the OR during Patient 1's procedure. These personnel were:

- Staff A: entered the OR at 1513 and left the OR at 1630;

- Staff B: entered the OR at 1614 and left the OR at 1650.

Review of documentation in Patient 1's medical record failed to include the position titles for Staff A and Staff B, the tasks performed by these individuals while in the OR, or the duties and responsibilities of these individuals while in the OR.

During an interview with Staff A on 12/22/2016 at 10:14 AM he/she stated that his/her position title at the hospital was "CNA II and Surgery Scheduler". He/she stated his/her job duties included, "taking VS", "bringing patients back [to the OR]" and "carrying out nurse and doctor orders within my scope".

Staff A stated during the interview that he/she had been called into the OR during a procedure on 2/24/2016 "because they didn't have a circulator [CN]". He/she stated that while in the OR during this procedure, he/she was asked to obtain a specimen container for Patient 1's gallbladder and obtain and open sterile suture packets. He/she stated that he/she felt "obligated" to go into the OR because the 2 nurses who had been in the OR "had already left for the day". He/she stated the OR Manager had directed him/her to the OR and "[he/she] [the manager] was the one delegating this so I felt obligated to do it". He/she also stated, "I was very uncomfortable about the whole thing, but the manager was telling me to do it....I felt like I really didn't have a choice. I'm disappointed I was put in that position. This could jeopardize my CNA".

The review of payroll records for Staff A revealed that on 2/24/2016, when Staff A was identified as having participated in Patient 1's surgical procedure, he/she was identified as the surgical scheduler/ward clerk and was coded as Unit Secretary 225.

The OR Manager stated, "Everyone on the team was aware [the scheduled scrub tech] had to leave [during Patient 1's procedure]. The team knew [he/she] had to leave during the procedure and they chose to go ahead [with the procedure]. There were 2 nurses who would not stay and help so they [the surgical team] was left in that situation. I would have done exactly the same thing if it was me."

During an interview with the OR Manager on 12/22/2016 at 11:00 AM he/she stated, "It's not part of the surgical scheduler/ward clerk's job description to help in the OR during surgical procedures. We don't have policies that are current for the employees to look at. Not policies have been revised since 2006. I don't know who develops policies and procedures for the surgical services department.

During an interview with the HRD on 12/22/2016 at 3:00 PM he/she stated, "It is never part of a [ward clerk's] job to participate in a surgery."

During an interview with Staff B on 12/21/2016 at 11:00 AM he/she stated that his/her job title was "Surgical Tech. It's still on my badge". He/she stated that he/she had been called into the OR on 2/24/2016 "In case they needed me to get something and open it for the scrub tech". He/she also stated, "I can help set up the room....get supplies ready. I can do everything for set up and tear down, so I can do everything except be in the OR during the procedure. I was filling in for [Staff A] because [he/she] had to leave". He/she stated that he/she was asked to go into the OR by Staff A.

Staff B confirmed during this interview that he/she did not have any of the certifications, qualifications, competencies, or surgical experience required to provide care and/or services in the OR.

The review of payroll records for Staff B revealed that on 2/24/2016, when Staff B was identified as having participated in Patient 1's surgical procedure, he/she was identified as a Surgical Technologist.

Record 2: Review of documentation revealed Patient 2 had an initial screening colonoscopy on 2/25/2016. Documentation on the intraoperative record identified Staff B as "Scrub Personnel" and that he/she was in the OR and participated in Patient 2's procedure.

Similar findings were noted in the remaining medical record reviewed (Record 3).

The review of documentation in personnel records for surgical staff revealed 8 of 13 staff (Staff A, B, C, D, E, F, G, and H) were performing duties outside of their scope of practice and that were not delineated in their job descriptions and/or they did not have the licenses and certifications required for their positions.

Staff A: Review of the personnel record for Staff A included an untitled job description for a ward clerk, date created 5/23/2012, last update 5/23/2012. The job description was not signed by Staff A or a manager.

Review of the job description for Staff A included a section titled, "Duties and Responsibilities." These duties and responsibilities included but were no limited to "....to provide clerical and organization assistance.....obtain admission information and insurance information....organize patient records and prepares charts". "Essential Duties" included but were not limited to, "Obtain insurance information/copies....make patient labels....file lab work, pre-op information, etc...deliver flowers to patients....take off new orders....keep paper supplies well stocked".

Documentation in the job description for Staff A failed to include any duties or responsibilities related to providing services or patient care in the OR during a surgical procedure.

Review of documentation in Staff A's personnel record revealed that Staff A did not have a current CPR and/or BLS certification.

Staff B: Review of documentation in the personnel record for Staff B revealed he/she was originally hired on 5/1/2009 in the position of "Housekeeper". Email documentation presented for review on 2/23/2017 at 2:21 PM from the HRD included an "Employee History" that indicated Staff B had a "status change" from "Housekeeper" to "Surgical Technologist" on 11/10/2014.

Review of a performance evaluation for Staff B dated 3/9/2015 identified him/her as a "Surgical Tech/Ward Clerk/Unit Secretary." The "Employee History" document indicated the date Staff B was transferred into the position of "Surgical Services Support Tech" was 1/3/2016.

The review of documentation in the personnel record included the "CVH Job Description for Surgical Technologist", date created 2/22/2016 (13 months after the "status change"), no update. A description of the job duties and responsibilities included but was not limited to, "Works under general supervision of Surgical Services Manager to provide......sterile processing, purchasing, and order responsibilities for the department. May need to assist with room turnover and terminal cleaning of O.R. Maintain par levels..........." This job description was not signed by Staff B or a manager.

Documentation in the job description included the education requirements for this position. These requirements included, "Graduate from a Surgical Technology technical school.....". Documentation in the job description included the licenses and certifications required for this position. The licensure and certification requirements for this position included, "CST or CORT certification" and "Must have Surgical Tech certification at time of hire." Documentation in the personnel record failed to reflect that Staff B had completed the required training or had the required licenses and certification for the position of "Surgical Technologist".

Staff B confirmed during an interview on 12/21/2016 at 11:00 AM that he/she did not have any of the certifications, qualifications, competencies, or surgical experience required to provide care and/or services in the OR.

During an interview with the HRD on 12/22/2016 at 2:53 PM he/she stated, "[Staff B] is not a surgical tech, all of our surgical techs are certified and [Staff B] is not certified." The HRD stated, "[Staff B] does sterile processing and assists with endoscope procedures."

Documentation presented for review on 12/22/2016 at 1:30 PM by the HRD included an incomplete "draft" job description that had been "created for Staff B". The draft job description was dated 1/21/2106 and titled, "Surgical Services Support Tech." The job description stipulated the following:

- "Qualifications: Cleans operating rooms between/after cases and share[s] responsibility for maintaining adequate supplies and appropriate equipment in Surgical Services;
- Education: High School Diploma or equivalent;
- Knowledge of anatomy and surgical instrumentation;
- College coursework or vocational/technical training preferred;
- Licenses/Certifications: Certified Surgical Technologist preferred but not required;
- Duties and responsibilities/Essential Functions: Cleans operating rooms between/after cases;
- Checks/maintains equipment/supply levels in each operating room, exchange carts, fluid warmers and the unit as a whole;
- Collaborates with Surgical Services team in the identification and resolution of problems related to environmental processes in the operating room;
- Assists with safe patient handling; lifting, turning and positioning;
- Transports patients;
- Obtains blood products form [sic] blood bank;
- Answers phones, miscellaneous clerical duties as assigned; and
- Ability to maintain confidentiality of all information related to patients, medical staff, and employees."

This draft job description failed to include any provisions for an employee in this position to work in the OR or provide care during surgical procedures.

The review of documentation and interviews failed to reflect that Staff B had signed, agreed to, or was aware of the requirements of this position based on the job description.

Staff C: The review of documentation revealed Staff C was employed by the hospital as a surgical technician. The licensure and certification requirements for this position included, "CST or CORT certification" and "Must have Surgical Tech certification at time of hire." Documentation in Staff B's personnel record failed to reflect that Staff C had completed the required training or had the required licenses and certification for the position of "Surgical Technologist".

Staff D: The review of documentation revealed Staff D was employed by the hospital until 3/15/2016 as an Operating Room RN. Documentation revealed an ACLS certification card with an expiration date of 7/2013. This indicated that Staff D had worked in this position for 2 years and 9 months without a current ACLS certification.

Documentation revealed that Staff D had a BLS certification card with an expiration date of 7/2013. This indicated that Staff D had worked in this position for 2 years and 9 months without a current CPR certification.

Documentation revealed that Staff D had a PALS certification card with an expiration date of 5/2014. This indicated that Staff D had worked in this position for 1 year and 10 months without a current CPR certification.

Review of documentation in the job description for an RN included the required certifications for this position. These certifications included, but were not limited to, "Current Oregon Registered Nurse licensure.....current BLS at date of hire....ACLS preferred."

Staff E: The review of documentation revealed Staff E was employed by the hospital as an RN. The review of documentation failed to reflect that Staff E had any of the certifications required for this position. These certifications included, but were not limited to, "Current Oregon Registered Nurse licensure.....current BLS at date of hire....ACLS preferred."

Staff F: The review of documentation revealed Staff F was employed by the hospital as a surgical technician. The licensure and certification requirements for this position included, "CST or CORT certification" and "Must have Surgical Tech certification at time of hire."

Review of additional requirements included in the personnel record for this position included, "Graduate from a Surgical Technology technical school, LPN program, RN program or military training program....LPN license if LPN, CST or CORT certification is required, must have surgical tech certification at time of hire, BCLS certification....(2) Years' Minimum of surgical assisting experience..."

Staff G: The review of documentation revealed Staff G was an OR Manager currently employed by the hospital. Documentation failed to include a job description for this position. Documentation in the job description presented for review included but was not limited to the following requirements, "Current Oregon Registered Nurse licensure.....current BLS at date of hire....ACLS preferred."

The review of documentation in Staff G's personnel records revealed an expired OSBN RN license. Documentation failed to reflect that Staff G had any current certifications required for this position.

Staff H: The review of documentation revealed Staff H was employed by the hospital as an OR RN. The review of documentation revealed that Staff H did not have any current licensure or certifications required for this position. These certifications included, but were not limited to, "Current Oregon Registered Nurse licensure.....current BLS at date of hire....ACLS preferred."

During an interview with the CEO and the CNO on 12/22/2016 at 1:00 PM the CEO stated, "Where are the current certifications?" The CNO stated, "I don't seem them." The CEO confirmed there was no additional documentation to reflect the employees had the licensure and certifications required for their positions.

Review of documentation included an undated document titled, "Surgery Department Staffing Policies". Documentation stipulated, "the operating room will be staff Monday-Friday 0700-1530 with two OR staff members, 2 RN's or 1 RN and 1 ORT."

Review of the hospital policy titled, "Scheduling Surgical Procedures" dated 5/29/2015 stipulated, "To notify the operating room department of the surgical or out-patient procedure so the staffing, equipment and supply needs of each patient can be safely met."

This policy failed to define the process and mechanism for scheduling and/or rescheduling procedures in the event there were not enough trained and qualified staff available to meet the care needs of the patients.