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Based on observation, record review and interview, the hospital failed to meet the requirements of the Condition of Participation for Nursing Services. The RN who was responsible for supervision and evaluation of the nursing care for each patient failed to ensure that care was provided in accordance with accepted standards of nursing practice and hospital policy relative to admission orders. As needed medication orders, laboratory testing, and diet orders upon admission were written and initiated by nursing staff without the prior ordering and approval of a physician/LIP for 1 of 1 (#R2) sampled patient who was observed during the admission process from a total patient sample of 10 (#1- #10) and a random patient sample of 6 (#R1- #R6). The admitting RN (S4RN) and 2 of 2 psychiatrists (S7Psych, S9Psych) interviewed indicated that physicians were not routinely called to review and provide verbal authorization for all admission orders that were written by nursing staff prior to the nurses implementing the orders. (See findings in tag A-0395).

Based on observation, record reviews, and interviews, the RN who was responsible for supervision and evaluation of the nursing care for each patient failed to ensure that care was provided in accordance with accepted standards of nursing practice and hospital policy relative to admission orders. This deficient practice was evidenced by failure to ensure as needed medication orders, laboratory testing, and diet admission orders were not written and initiated by nursing staff without the prior ordering and approval of a physician/LIP for 1 of 1 (#R2) sampled patient who was observed during the admission process from a total patient sample of 10 (#1- #10) and a random patient sample of 6 (#R1- #R6). The admitting RN (S4RN) and 2 of 2 psychiatrists (S7Psych, S9Psych) interviewed indicated that physicians were not routinely called to review and provide verbal authorization for all admission orders that were written by nursing staff prior to the nurses implementing the orders.

Findings:

Review of the Statutory Definition for RN Scope of Practice R.S. 37:913 revealed the following, in part: (13) "Practice of Nursing" means the performance, with or without compensation, by an individual licensed by the board as a registered nurse, of functions requiring specialized knowledge and skills derived from the biological, physical, and behavioral sciences. The practice of nursing or registered nursing shall not be deemed to include acts of medical diagnosis or medical prescriptions of therapeutic or corrective nature.

Review of the hospital policy titled, "Verbal and Telephone Orders", Policy Number: Nur 005, effective date: 1/2013, last revised 1/28/19, revealed in part: Policy: It is the policy of this hospital that orders for medication/treatment shall be administered/carried out only upon the order of any physician, or individual who has been granted clinical privileges by the Medical Director to write such orders.

Procedure:
I. Only physicians and nurse-practitioners, or other health professionals as defined in the Medical Staff by-laws, Rules and Regulations may write orders. Authorized prescribers may write orders according to their licensing bodies' guidelines and this hospital's policies and procedures.

II. All orders for medication/treatment shall be written on the doctors' order sheet.

III. Verbal and Telephone orders
a. A verbal or telephone order may be dictated to a duly authorized person (licensed nurse, pharmacist, etcetera) functioning within his/her sphere of competence in accordance with their licensing board who transcribes the order onto the doctor's order sheet.
b. All verbal orders shall contain the signature of the appropriate authorized person and the name of the prescribing physician.
c. The prescribing physician or other practitioner who is responsible for that patient's care shall authenticate such orders within the next 10 days by countersigning the orders.
d. Any verbal order given will be read back and verified by the authorized individual taking the verbal order.
e. A "Read Back and Verified" will be written on the order sheet, by the authorized person receiving the order.
f. Signature of physician/authorized prescriber and unique identifier.

Review of the hospital's document titled, "Physician's Admit Orders and Problems List", revealed the orders were pre-printed sheets with boxes next to various orders that could be "checked" to indicate an order had been selected. Further review revealed the selections included orders for labs, diets, precautions, observation levels, drug levels, and vital sign frequency.

Review of Patient #R2's medical record revealed an admission date of 11/18/19 at 2:25 p.m. with an admission diagnosis of psychosis. Further review revealed the patient's legal status was PEC due to being gravely disabled.

Review of Patient #R2's admit orders, dated 11/18/19 at 2:25 p.m. revealed the following orders had been checked: Vital signs twice a day with parameters for physician notification; Accu-check on admit; Weight on admit then every Sunday a.m.; Dietary consult: blank.;

Further review revealed a section of the document used for ordering levels of observation and special precautions. Additional review revealed patients were admitted with standard q 15 minute observations (unless indicated by physician's orders).

Patient #R2 was admitted on a q 15 minute observation level with no special precautions (types of special precaution choices were noted to include seizure, fall, suicide, elopement, and homicidal). Additional review revealed a box to check to indicate an order for 1:1 Observation level (not checked for this patient).

The section with the heading "Initial Diet to order upon admission" included the following options to choose for diet:
If history of Diabetes Mellitus then 1800 calorie ADA diet;
If history of cardiac disease then low salt diet;
If history of dysphagia then chopped diet; and
If not within above parameter - Regular Diet.

The diet ordered via check mark for Patient #R2 was a Regular Diet.;

The Diagnostic Tests section of the orders indicated the following diagnostic tests were to be done on all admits if not done in Emergency Room: Syphilis TP, Lipid Panel, EKG (electrocadiogram), UDS ( urine drug screen), CBC ( complete blood count) with Differential, UPT (urine pregnancy test) on women under 60, PT (prothrombin time) /INR (international normalized ratio) if on Coumadin on admit and every Monday and Thursday, and Drug Trough levels for Depakote, Lithium, Tegretol, and Dilantin.

Labs checked for Patient #R2 were Syphilis TP and Lipid panel.

Additional review of a section titled, "Medications" revealed check boxes to initiate the following PRN (as needed) medications:
Tylenol 650 mg p.o. q 6 hours PRN mild pain/fever > ( greater than) 100 degrees Fahrenheit if no history of or current liver disease; Ibuprofen 200 mg 2 tabs p.o. q 6 hours, as needed moderate pain ( if on Lithium do not order Ibuprofen); Maalox 30 ml p.o. q 6 hours PRN gastric distress; Milk of Magnesia 30 ml p.o. q 12 hours PRN for constipation; MVI: p.o. daily for nutritional supplement; Zofran 4 mg p.o. q 6 hours PRN nausea; Imodium 2 mg cap p.o. q 4 hours PRN diarrhea, Dulcolax 5 mg p.o. daily PRN constipation.

All of the above referenced medications had been checked on Patient #R2's admission orders.

The admission order had been written by S4RN as a TORB x 2 (telephone order read back times 2) from S9Psych on 11/18/19 at 3:00 p.m.

Review of Patient #R2's "Physician Order/Admission Medication Reconciliation" form revealed the form was used to reconcile the patient's previous medications and to determine whether the patient's previous medications were to be continued on admission or discontinued (indicated by 2 columns titled," Yes" to continue or "No" to discontinue). Further review revealed the form had a handwritten notation indicating the patient had "no home meds". Additional review revealed the orders had been written by S4RN as a TORB x 2 (telephone order read back times 2) from S8MD on 11/18/19 at 3:00 p.m.

On 11/18/19 at 2:25 p.m. an observation was made of S4RN admitting Patient #R2. S4RN reported the nurses assessed the patients on admission and would text the admitting MD with the assessment results and medications. S4RN confirmed the admitting nurses chose patients diets based on information from the patient's emergency room records or from the transferring facility. S4RN reported she reviewed the patient's medications and sends the medication information via text, on her personal phone, to the MD. S4RN explained the physician then responds and lets them know if they agree or if they want to change medications. S4RN reported she would not call S9Psych for Patient #R2's admission orders because he was not admitted on any medications. S4RN indicated she was choosing/checking off Patient #R2's PRN medication orders, diet orders, labs, and other orders on the admission orders. S4RN confirmed she was documenting the orders as read back telephone orders times 2 and signing S9Psych's name as being the MD called for TORB orders.

In an interview on 11/18/19 at 3:21 p.m. with S2DON, she indicated the physician should be called to review the condition of the newly admitted patient and to review medications.

On 11/20/19 at 10:30 a.m. a request was made to conduct a telephone interview with S8MD. S1Adm showed the surveyor a text from S8MD indicating he was ill and unable to participate in an interview.

In an interview on 11/20/19 at 10:39 a.m. with S9Psych, he indicated many of the hospital's inpatients were admitted late in the afternoon or in the middle of the night. He reported the patients were usually admitted under the auspices of the MD on call. He indicated he does not take call. S9Psych reported if the patients were admitted during the day the nurses filled out the orders as verbal orders from somebody who is a member of the medical staff. S9Psych indicated the orders are filled out as verbal orders. S9Psych further reported he would sign off on the verbal orders when he came in if his name was on the verbal order. S9Psych indicated he would also sign off on verbal orders if the on-call MD had not signed off on the orders at the time of his review. S9Psych reported the nursing staff would get information for medication reconciliation from the patients or from their records. He indicated the on call MD decided whether medications were to be continued or discontinued on admission. S9Psych explained the medications were reviewed for changes when the psychiatric evaluation was performed.

In an interview on 11/20/19 at 11:12 a.m. with S7Psych, he reported the nursing staff called or texted information to the physician for a new admit. He indicated they needed to determine if potential patients were suitable for admission, for example, to ensure they were not too medically complex to be admitted. He confirmed the admitting nurse initiated new patient admit orders without calling the physician if the patient was admitted without having been on medications prior to admission. S7Psych also confirmed the PRN medications on the admission orders were initiated on all patients, by the nursing staff, unless contraindicated due to patient history, such as not ordering Tylenol PRN if the patient has a history of liver disease.

S7Psych reported the patients' diets were chosen based on history and they were placed on a routine diet, unless they were Diabetic, then they were placed on a Diabetic diet. S7Psych indicated if a patient had dental issues the chopped diet would have been initiated. S7Psych also indicated the labs ordered on the patients were based upon whether or not labs were performed at the transferring hospital or facility. He reported, for example, if the patient was on Depakote and no serum level had been performed, then the nurse would check off the Depakote level order.

In an interview on 11/20/19 at 12:19 p.m. with S3Risk, S1Adm, and S2DON, they verified the MD should be called for patient admission orders and all orders should be reviewed and obtained from the admitting physician. They confirmed no part of the admission orders are to be chosen by the nurse independent of verifying each order with the physician.

Based on record review, observation, and interview, the hospital failed to ensure drugs and biologicals were prepared and administered in accordance with hospital policy and procedure and acceptable standards of practice. This deficient practice was evidenced by failing to crosscheck Insulin (high alert/risk medication) with another nurse prior to administration for 2 (#2, #5) of 4 (#2, #3, #5, #7) Diabetic patients reviewed from a total sample of 10 patients.

Findings:

Review of the hospital policy titled, "Administration of Insulin", presented as current policy, revealed in part. ...Two nurses should verify that the correct dosage and type of insulin is in the syringe prior to administration.

Review of the hospital policy which was from Pharmacy "A" revealed in part, High Alert medications ....Recommend all facilities to instruct Nursing Staff to include the following when administering High Alert Meds: Included in this is to crosscheck of meds and dose with another member of the Nursing staff prior to administration.

Review of the personnel files for S5LPN and S6LPN revealed a section titled, " Job Specialty/Orientation/Competency" which had a subsection titled, "Insulin Administration". Further review revealed S5LPN and S6LPN had signed, as confirmation of acknowledgement, that he/she was to cross check the MAR and Insulin type and have a second nurse verify the insulin dose when administering Insulin.


Patient #2
Review of the medical record for Patient #2 revealed he was a 48 year old diagnosed with Diabetes Mellitus.

An observation 11/18/19 at 11:34 a.m. revealed S5LPN checked a CBG on Patient #2. The CBG was 261. Regular Insulin 6 units were administered as ordered without a second nurse crosschecking the MAR and the dose.

In an interview on 11/18/19 at 12:45 p.m. with S5LPN, she stated she does not check Insulin dosages with another nurse.

Patient #5
Review of the medical record for Patient #5 revealed he was a 48 year old diagnosed with Diabetes Mellitus.

An observation on 11/18/19 at 11:20 a.m. revealed S6LPN checked a CBG on Patient #5. The CBG was 324. Regular Insulin 8 units were administered as ordered without a second nurse crosschecking with the MAR and the dose.

In an interview on 11/18/19 at 12:36 p.m. with S6LPN, she stated she never gets another nurse to verify Insulin. She further stated it is not policy to verify Insulin with another nurse.

In an interview on 11/18/19 at 3:21 p.m. with S2DON, she stated two nurses should check insulin before giving it if there is another nurse available, but if not she would just check it herself twice. She said it should not be checked by an MHT as the second person. She said she had only been here since 10/14/19 and wasn't sure what the hospital policy was.

Based on record review, observations, and interviews the hospital failed to ensure the Medical Records were maintained in accordance with written policies and procedures as evidenced by:
1. failure of the hospital to ensure patient medical records were promptly completed as set forth in the hospital's policies for completion of medical records and failure to enforce consequences for delinquent medical records as set forth in the hospital's policies and Medical Staff Rules and Regulations; and
2. failure of the hospital to ensure the Medical Records were protected from environmental elements such as water and fire damage.

Findings:

1. The hospital failed to ensure patient medical records were promptly completed.

Review of the hospital policy titled Record Retention presented as current policy revealed in part, the medical record shall be closed no later than 30 days after patient discharge.

Review of the Medical Staff Rules and Regulations revealed in part, the medical staff will review chart closure within 30 days to monitor deficiencies as part of the ongoing professional practice evaluation. Based on the recommendation of the medical staff through peer evaluation, medical staff may choose to suspend the practitioner and put the same practitioner and he/she is unable to close the medical record within 30 days, the medical staff may choose to recommend termination of that LIP's privileges.

Review of the medical record deficiency log presented on 11/19/19 by S10MRDir revealed 379 records were over 30 days delinquent. This list begins with a discharge date of 9/1/19. S10MRDir said there is no record available for the delinquent medical records for patients with a discharge date before 9/1/19.

In an interview on 11/19/19 at 10:30 a.m. with S10MRDir, she stated she has worked as Medical Records Director for 6 years and has not sent any delinquent or suspension of privileges letters to any licensed independent practitioner. She further revealed the hospital computer system "crashed" on 8/23/19 and she has not had the time to update the list of delinquent medical records which was lost (those patients with delinquent medical records discharged before 9/1/9).

In an interview on 11/19/19 at 1:20 p.m. with S11MRCor, she stated she was aware there was a breach in the computer system, but she was not aware everything was not "back whole". She further stated she was not aware the deficiency log was not up to date.

2. The hospital failed to ensure the Medical Records were protected from environmental elements such as water and fire damage.

Review of the hospital policy titled Record Retention presented as current policy revealed in part, closed medical records kept on-site will be stored in the locked medical records department and kept in closed cabinets to protect them from fire, water damage, or other threats.

An observation on 11/19/19 at 9:45 a.m. with S10MRDir and S3Risk of the medical records room in the hospital revealed 4 carts with 3 rows on each cart full of medical records and an additional two stacks of medical records on top of a desk. All of these medical records were said to be current delinquent records. These medical records were uncovered and exposed to sprinklers which were located in ceiling of the room.

An observation on 11/19/19 at 10:00 a.m. with S3Risk of the medical records department in Building "B" revealed 71 uncovered cardboard bankers boxes filled with medical records stacked on pallets in a room that had no sprinklers. Further observations revealed 22 uncovered cardboard bankers boxes filled with medical records stored on top of shelves in the room with no sprinklers.

On 11/19/19 at 10:00 a.m. the above findings were verified by S3Risk.

Based on record review and interview, the hospital failed to have a procedure for ensuring the confidentiality of patient records. This deficient practice is evidenced by nurses texting PHI to physicians on their private, unsecured telephones.

Findings:

Review of the hospital policy titled, "Hospital Text Communication", presented as current policy, revealed in part: All text messages containing ePHI is prohibited ... Medication orders should never be sent via text communication.

In an interview on 11/18/19 at 2:25 p.m. with S4RN, she revealed the charge nurse does her assessment, obtains signed consents, and then texts the physician, on her telephone, the assessment results and patient medications. She further stated she does not call the physician; she sends information via texts and the doctor will let them know if they agree or want to change medications.

In an interview on 11/18/19 at 3:21 p.m. with S2DON, she verified the admitting nurse should call the doctor in order to go over the condition of the patient and the patient's medications.

In an interview on 11/20/19 at 11:12 a.m. with S7Psych, he revealed when a patient is admitted the nurses would text him a picture of the patients' medication list to his personal cellular phone.

In an interview on 11/20/19 at 1:30 with S1Adm, he revealed the facility does not have a cyber-safe security system on their cellular phones. He said this includes the cellular phone which is supplied by the hospital in the Admissions Department. S1Adm verified the nurses sent screen shots of the filled out physician's order sheets from their personal cellular phones and/or the admissions cellular phone to the physician's personal cellular phones. He said this is the quickest way to obtain the physician's response.

Based on record review and interviews, the hospital failed to ensure the hospital medical records contained a discharge summary for 2 (#R3, #R4) of 3 (#R3, #R4, #R5) discharged patient records reviewed.

Findings:

Review of the Medical Staff Ruled and Regulations revealed in part, a discharge summary shall be written on all patients hospitalized. The summary must include the reason for hospitalization, significant findings, the procedures performed and treatment(s) rendered, condition of patient on discharge, and discharge instructions and medications. All summaries shall be signed by the responsible staff member. The Discharge Summary is required to be completed within 30 days of the patient's discharge.

Review of the hospital policy titled Documentation presented as current policy revealed in part, Discharge Planning and Post Discharge Documentation: ...A Physician's discharge summary is required by the 30th day after discharge ...

Patient #R3
On 11/20/19 a review of the medical record for Patient #R3 revealed an admission date of 9/4/19 and a discharge date of 9/10/19 (70 days). Further review of the medical record failed to reveal a discharge summary.

In an interview on 11/20/19 at 11:20 a.m. with S3Risk, he verified there was no discharge summary in the chart of Patient #R3.

Patient #R4
On 11/20/19 a review of the medical record for Patient #R4 revealed an admission date of 9/19/19 and a discharge date of 10/2/19 (48 days). Further review of the medical record failed to reveal a discharge summary.

In an interview on 11/20/19 at 11:30 a.m. with S3Risk, he verified there was no discharge summary in the chart of Patient #R4.

Based on record review and interview, the hospital failed to ensure the hospital's contracted radiological services were supervised by a qualified radiologist on a part-time, full-time, or consulting basis. This deficient practice was evidenced by the hospital appointing S8MD (Internal Medicine MD) to serve as the director of the hospital's contracted radiological services.

Findings:

Review of the hospital's contracted services revealed a contract with mobile x-ray Company
"B".

Review of the hospital's organizational chart revealed radiological services was listed as being under the supervision of S8MD.

Review of S8MD's contract with the hospital revealed he had been appointed to serve as supervising physician for the hospital's contracted radiological services. Further revealed S8MD is a medical physician specializing in Internal Medicine and Addiction and is not a Radiologist.

In an interview on 11/19/19 at 10:10 a.m. with S8MD, he confirmed he was the supervising physician of the hospital's contracted radiological services.

In an interview on 11/20/19 at 2:30 p.m. with S1Adm, he confirmed S8MD was appointed to be the supervising physician of the hospital's contracted radiological services.

Based on observations, record reviews, and interviews, the hospital failed to meet the requirments of the Condition of Participation of Infection Control. This deficient practice was evidenced by:

Failure of the infection control officer to develop a system for controlling infections and communicable diseases of patients and personnel by failing to ensure a capillary blood glucose monitoring device was properly disinfected by nursing staff after performance of capillary blood glucose sampling for 3 (#2, #3, #5) of 4 (#2, #3, #5, #6) patients observed for capillary blood glucose monitoring from a total patient sample of 10 (#1-#10) and a random patient sample of 6 sampled (#R1- #R6). This deficient practice had the potential to impact all patients admitted to the hospital due to capillary blood glucose monitoring being performed on all patients on admission. There were currently three inpatients (#8, #R1, #R6) who were positive for Hepatitis C and four current Diabetic inpatients (#2, #3, #5, #7) at the time of the survey. (See findings at A-0749).

Based on record review, observation, and interview, the hospital failed to ensure the infection control officer developed a system for controlling infections and communicable diseases of patients and personnel. This deficient practice is evidenced by failing to ensure a capillary blood glucose monitoring device was properly disinfected by nursing staff after performance of capillary blood glucose sampling for 3 (#2, #3, #5) of 4 (#2, #3, #5, #6) patients observed for capillary blood glucose monitoring from a total patient sample of 10 (#1-#10) and random patient sample of 6(#R1- #R6). This deficient practice had the potential to impact all patients admitted to the hospital due to capillary blood glucose monitoring being performed on all patients on admission. There were currently three inpatients (#8, #R1, #R6) who were positive for Hepatitis C and four current Diabetic inpatients (#2, #3, #5, #7) at the time of the survey.

Findings:

Review of the hospital policy titled, "Accu-check Equipment Management/Cleaning", policy number: IC - 034, last revised 2/4/19, revealed in part: Purpose: To prevent contamination of infection while using the Contour Accu-check device. Procedures: 2. The Accu-check machine should be wiped using the Sani-wipes provided by the organization (purple top Sani-wipes).

Review of documentation found at FDA.gov relative to disinfection of capillary blood glucose monitoring systems revealed the following information, in part: 2. Validated cleaning and disinfection procedures: a. The disinfection solvent used should be effective against HIV, Hepatitis B virus, and Hepatitis C virus. Outbreak episodes have been largely due to transmission of Hepatitis B and C viruses. However, of the two, Hepatitis B virus is the most difficult to kill. Please note that 70% ethanol solutions are not effective against viral blood-borne pathogens.

Review of the Contour Blood Glucose Monitoring System user guide, presented by S2DON on 11/18/19 at 11:48 a.m., revealed the following, in part: Caring for the System: The exterior of the meter can be cleaned using a moist (not wet), lint-free tissue with a mild detergent or disinfectant solution, such as 1 part bleach mixed with 9 parts water.

On 11/18/19 at 11:20 a.m. an observation was made of S6LPN (A- Hall) performing blood glucose monitoring on Patient #5. S6LPN was observed cleaning the glucose meter with PDI Sani-Hands Instant Hand Sanitizing Wipes (Blue top wipes) after she had obtained the patient's capillary blood glucose sample. Observation of the blue top container of PDI Sani-Hands Instant Hand Sanitizing Wipes, by the surveyor, revealed the active ingredient in the cloths was Alcohol 70% by volume.

In an interview, during the observation on 11/18/19 at 11:20 a.m., S6LPN confirmed she had used the blue top PDI Sani-Hands Instant Hand Sanitizing Wipes to clean the capillary blood glucose meter. She further confirmed the referenced PDI wipes were 70% alcohol and were to be used for hand disinfection and not for disinfection of equipment to prevent blood borne disease transmission.

In an interview on 11/18/19 at 2:20 p.m. S6LPN indicated at around 7:00 a.m. on 11/18/19, S2DON had instructed them to use the PDI Sani-Hands Instant Hand Sanitizing Wipes (the blue top container) for cleaning the capillary blood glucose meter between patients.

On 11/18/19 at 11:34 a.m. an observation was made of S5LPN performing blood glucose monitoring on Patients #2 and #3. S5LPN was observed cleaning the glucose meter with the blue top PDI Sani-Hands Instant Hand Sanitizing Wipes (Active ingredient- Alcohol 70% by volume) after she had obtained the patients' capillary blood glucose samples.

In an interview during the observation on 11/18/19 at 11:43 a.m., S5LPN reported she always uses the PDI Sani-Hands Instant Hand Sanitizing Wipes with the blue top to clean the capillary blood glucose meter. S5LPN further reported she had used the PDI Sani-hands wipes for cleaning the capillary blood glucose meter since she had started working at the hospital in May 2019.

In an interview on 11/18/19 at 2:30 p.m. with the infection control office S3Risk, he confirmed a capillary blood glucose test was performed on all patients on admission and not just on the Diabetic patients. S3Risk further confirmed there were currently 4 Diabetic inpatients (#2, #3, #5, and #7) and 3 inpatients (#8, #R1, #R6) who were positive for Hepatitis C. S3Risk also confirmed there were currently two capillary blood glucose meters in use (1 meter on "A" Hall and 1 meter on "B" Hall).

In an interview on 11/18/19 at 3:21 p.m. with S2DON, she confirmed she had told the medication nurses on both "A" Hall and "B" Hall to stop using the Sani-wipes (purple top disinfectant) and to begin using the blue top PDI Sani-Hands Instant Hand Sanitizing Wipes to clean the capillary blood glucose monitoring device. She reported she had made this decision because she had planned to start using a different capillary blood glucose meter. S2DON verified the Contour instructional manual had provided an option for use of a bleach and water solution for disinfection of the device. S2DON reported she had been unaware that the patient equipment used on multiple patients needed to be disinfected in-between patients in order to prevent transmission of blood borne illnesses. She reported she thought it just had to be cleaned between patients.

Based on record reviews and interview, the hospital failed to ensure the nursing staff providing respiratory care were trained and determined to be competent in performance of respiratory care functions. This deficient practice was evidenced by failure to have documented evidence that education and evaluation of competency in the administration of multi-dose respiratory inhalers had been conducted for 3 (S4RN, S5LPN, S6LPN) of 3 direct care staff nurses' personnel files reviewed.

Findings:

Review of personnel files for S4RN, S5LPN, and S6LPN revealed no documented evidence of education and competency evaluation for administration of multi-dose respiratory inhalers.

In an interview on 11/19/19 at 3:18 p.m. with S3Risk, he confirmed nurses administered patients' multi-dose respiratory inhalers. S3Risk indicated nurses are not specifically trained for administering patients' multi-dose respiratory inhalers. S3Risk explained nurses were not trained/competenicies evaluated because the assumption was that the nurses were already proficient in administering inhaled medications.