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Based on the potential for patient injury or harm that can result when medications are administered by personnel who are not trained and licensed to perform these duties, it was determined the condition for compliance with state codes is not in compliance (See C0152).

Based on document review, observations, staff and other professional interviews it was determined the hospital failed to comply with West Virginia Code Title 64, Series 60 for medication administration by allowing unlicensed personnel to administer intramuscular and intravenous medications. This deficient practice was found in one (1) of one (1) medical record reviewed (patient #20) and one (1) of one (1) medical assistants interviewed (MA1) in an outpatient department internal medicine practice site located off campus in town. When employees administer medications who are not trained and licensed to perform these duties, it results in violations of state code with possible medication errors that can cause patient injury or adverse events.

Findings include:

1. West Virginia State Code for medication administration states in part the following are the only situations in which medications may be administered by unlicensed personnel:
64-60-2. Definitions
2.1. Administration of medication-
2.1.a. Assisting a person in the ingestion, application or inhalation of medications or insertion of rectal or vaginal medications.
The code states that only trained personnel which have been approved as medication assistive personnel (AMAP) can provide this service in specific settings which does not apply to hospitals. The legislation does not recognize medical assistants as having the authority or scope of practice to administer any medications.

2. The Executive Director for the West Virginia Board of Nursing had been previously consulted by phone on 2/22/11 at 1100 hours concerning administration of medications by non-licensed personnel. At that time she stated according to nursing standards a nurse may not delegate administration to an unlicensed person whose scope of practice does not include the administration of medications.

3. A tour of an offsite internal medicine practice, which is listed as a department of the hospital, was done on 5/15/12 at 1515 hours. This practice is open weekdays from 8:30 AM to 4:30 PM. At the time of the tour no patients were receiving care by the staff and all of the scheduled patients had been cancelled due to a power failure in the area. The surveyors used flash lights to conduct the tour and were unable to perform an extensive inspection. During this tour the office staff, which consisted of medical assistants and clerical personnel, were questioned as to who the Licensed Practical Nurse (s) or Registered Nurse (s) were. The staff all answered they do not have any nurses.

Medical Assistant #1 (MA1) was questioned as to who gives injectable or intravenous medications and she explained that herself and the other medical assistants give the medications. MA1 added the phlebotomist will sometimes give the intravenous medications since they are usually better at accessing veins. When asked what medications the staff gives MA1 stated they administer Lasix, Toradol, B12, Solu Medrol and allergy shots.

At 1530 hours. MA1 was asked if she has given any intravenous medications and she stated yes and presented Patient #20 medical record.

4. Review of the patient record #20, on 5/15/12 at 1530 hours, revealed the patient had an office visit on 4/30/12. MA1 had documented, under the procedure section, the administration of Lasix 160 milligrams (mg) by intravenous push (IVP). There was no documented time the medication was given, the amount of time over which the medication was administered, site of injection and patient response. MA1 stated she had given this medication and when asked if the medication had been diluted she thought maybe 1 cubic centimeter (cc) of saline but wasn't sure what mark on the syringe she used for the saline. Vital signs were recorded during this visit however there was no time when they were taken. MA1 said the patient left the office that day and has been back a couple of times.

The office staff was informed at the completion of the unit tour on 5/15/12 at 1545 hours that medical assistants are not legally authorized to administer any type of medication.

The job description (current) for a medical assistant for internal medicine was reviewed. The general job functions are to provide assistance to the medical staff, greet patients, activate files and prepare patient as needed to move though the office appointment. Must be able to understand and carry out medical directives and multi task. Performs other duties as required.
The job description and qualifications do not include medication administration.

5. At 1645 hours on 5/15/12 the hospital president and vice president of nursing conferred with the survey team concerning the findings at the internal medicine unit. They both agreed that medical assistants can not administer medications and both asserted this practice will be stopped at that time.

Record #20 was reviewed with the hospital president on 5/16/12 at 1000 hours and he agreed with the findings and the fact that 160 mg of Lasix is a large dose. Additionally, he stated the physician at the internal medicine office will be administering all medications until the hospital can staff the unit with a licensed nurse.

Based on observations and staff interview it was determined that infection control failed to ensure that medications are stored in an area that is free from sources of cross contamination such as laboratory specimens. Failure to store medications in an area which is free from biohazard items can result in the cross contamination of medications with possible patient infections or harm.

Findings include:

1. A tour of an off site internal medicine practice, which is listed as a department of the hospital, was done on 5/15/12 at 1515 hours. In room 6 was a refrigerator that contained multiple medications. In the door of the refrigerator was a biohazard bag containing a urine specimen which was located on top of some medications.

2. The Medical Assistant 1(MA1) who was present during the tour was questioned as to if they had a specimen refrigerator. The MA1 stated "no" they use the refrigerator where the medications are stored to put their specimens until they are sent to the laboratory.

Based on staff interview and medical record review, it was determined the hospital failed to ensure that nursing is actively engaged in supervising and evaluating nursing and patient care that is being provided at an outpatient department internal medicine practice site located off campus in town. Additionally, nursing failed to ensure that all personnel administering medications are duly licensed to perform these duties (patient #20). Failure to supervise and ensure that nursing personnel are performing their duties according to clinical standards and within their scope of practice and license has the potential to result in adverse patient events.

Findings include:

1. A tour of an off site internal medicine practice, which is listed as a department of the hospital, was done on 5/15/12 at 1515 hours. During this tour the office staff, which consisted of medical assistants and clerical personnel, were questioned as to who the Licensed Practical Nurse (s) or Registered Nurse (s) were. The staff all answered they do not have any nurses.

Medical Assistant #1 (MA1) was questioned as to who gives injectable or intravenous medications and she explained that herself and the other medical assistants give the medications. MA1 added the phlebotomist will sometimes give the intravenous medications since they are usually better at accessing veins. When asked what medications the staff gives MA1 stated they administer Lasix, Toradol, B12, Solu Medrol and allergy shots.

2. Review of the patient record #20, on 5/15/12 at 1530 hours, revealed the patient had an office visit on 4/30/12. MA1 had documented, under the procedure section, the administration of Lasix 160 milligrams (mg) by intravenous push (IVP). There was no documented time the medication was given, the amount of time over which the medication was administered, site of injection and patient response. MA1 stated she had given this medication and when asked if the medication had been diluted she thought maybe 1 cubic centimeter (cc) of saline but wasn't sure what mark on the syringe she used for the saline. Vital signs were recorded during this visit however there was no time when they were taken. MA1 said the patient left the office that day and has been back a couple of times.

At 1645 hours on 5/15/12 the hospital president and vice president (VP) of nursing conferred with the survey team concerning the findings at the internal medicine unit. They both agreed that medical assistants can not administer medications and both asserted the practice will be stopped at that time. The VP of nursing agreed she was unaware of what was occurring at the internal medical office and had not been actively involved with the supervision of the personnel in this office.