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Based on document review, staff interview, observation and the NFPA (National Fire Protection Association) 101 Life Safety Code 2000 Edition, the hospital failed to: maintain smoke barrier walls providing at least a one half (1/2) hour fire resistance rating (see tag K 025); failed to maintain the fire alarm system in accordance with NFPA 72 (see tag K 052); and, failed to maintain the sprinkler piping in accordance with NFPA 25 (see tag K 062).

Based on staff interview, document review and record review it was determined the facility failed to ensure medications were administered in accordance with accepted standards of practice and hospital policy by allowing an unlicensed person to administer medications to patients who were in the Emergency Department (ED). This failure has the potential for patients to be given medication in an unsafe manner.

Findings include:

1. During a tour of the ED on 11/3/15 at 9:45 a.m., the ED Nurse Director discussed the physician and nursing staffing. He stated there are always two (2) registered nurses (RNs) and one (1) physician present to staff the ED. He stated there are no mid-level providers staffing the ED. He also stated there is one (1) Medical Assistant (MA) who works 2:00 p.m. to 10 p.m. five (5) days per week. He stated the MA is an unlicensed person who assists the staff in checking vital signs, dressing changes, medication administration and other duties as assigned. He stated the MA administers non-narcotic medications both PO (by mouth) and IM (intramuscularly) and does so under the supervision of either the RN or the physician.

2. Review of the "Position Description/Performance Evaluation" for the "Emergency Department Medical Assistant", last revised 9/13, revealed it stated, in part: "Duties and Responsibilities...Carries out physician orders, i.e. administering medications, specimen collection, preparing patients for procedures....Under the direct supervision of a Registered Nurse (and upon clinical competency verified by the ED Director), the Medical Assistant may perform: ...Medication administration: PO, IM, SQ (sub-cutaneous), topical, per rectum."

3. Review of the personnel file for the MA revealed she was hired 10/24/13. The personnel file was reviewed with the ED Nurse Director on 11/3/15 at 2:15 p.m. The MA completed a medical administrative assistant training program in 1990. There was no MA type work history listed on the application. There was no licensure or certification in the personnel file, only a transcript from the 1990 training program. There was no specific medication administration training listed on the transcript. There was no specific training or competency evaluation included in the personnel file for the administration of medication other than the annual evaluations completed on 8/4/14 and 8/10/15 on which it was noted she "met" expectations for administering medications.

4. Review of hospital policy, "Administration of Medications", last revised 3/15, states, in part: "Who may administer medications?... 1. Registered Nurse 2. Licensed Practical Nurse (LPN) 3. Graduate Nurses until first Board Exam results failure 4. Student Nurses (LPN and RN) with supervision of clinical instructor." The policy did not include the unlicensed or uncertified MA as a person who can administer any medications. A different version of the same policy, also dated 3/15, was provided later in the survey. The second policy indicated the MA could administer medications via oral, intramuscular and subcutaneous routes. During interview with the Vice President of Patient Care services on 11/4/15 at 11:55 a.m., she stated the second policy was on the hospital intranet and had not been printed and placed in the manual which was given to the surveyors for review.

5. Review of the West Virginia RN Board of Nursing's, "Criteria for Determining Scope of Practice for Licensed Nurses and Guidelines for Determining Acts That May be Delegated or Assigned by Licensed Nurses", revised 3/15, revealed it included the following information: "Guidelines for Assigning Tasks to Unlicensed Personnel - There is a need and a place for competent, appropriately supervised, unlicensed assistive personnel in the delivery of affordable, quality health care. However, it must be remembered that unlicensed assistive personnel are to assist - not replace - the nurse. This, unlicensed assistive personnel should be assigned to the nurse to assist with patient care rather than be independently assigned to the patients. Activities That May be Assigned to an Unlicensed Person - Nursing practice assigned to unlicensed assistive personnel is limited to performance of the basic nursing care services, such as taking vital signs, providing personal hygiene, comfort, nutrition, ambulation and environmental safety and protection. Unlicensed workers are PROHIBITED from performing any licensed nursing function that is specifically defined for licensed nurses in the nursing practice acts or rules of the Boards of Nursing, except as specifically provided in West Virginia Code and Rules (AMAPS [Approved Medication Administration Personnel], School Nurse, Dialysis Techs, EMS [Emergency Medical Services], etc.)...The Boards receive questions about delegation to medical assistants. Medical assistants are unlicensed personnel and have no defined scope of practice, have no laws or rules governing practice and may not be delegated activities by the nurse that require professional licensure (i.e. intravenous medication administration)."

6. Review of the current West Virginia Code to State Regulations Chapter 16 Article 50 Section 1 revealed the article pertains to "Medication Administration by Unlicensed Personnel" and it states, in part: "As used in this article the following definitions apply: 'Facility' means an intermediate care facility for individuals with an intellectual disability, assisted living, behavioral health group home, private residence in which health care services and health maintenance tasks are provided under the supervision of a registered professional nurse as defined in article seven, chapter thirty of this code." Acute care hospitals and critical access hospitals are not named in the article as an appropriate or approved "facility" that can allow an unlicensed person to administer medications under West Virginia law.

7. The use of an unlicensed Medical Assistant to administer medications to patients in the ED was discussed extensively with the ED Nurse Director on 11/3/15 starting at 2:15 p.m. He stated the ED needed a "third" RN during part of the 24-hour shift and the decision was made to hire an MA instead of an RN to assist the two (2) RNs with their duties. He concurred during the discussion that the use of an unlicensed person to administer medications was not appropriate for the critical access hospital setting after reviewing the MA's personnel file, selected policies, medical records and other documents.