HospitalInspections.org

Based on record review and interview, the hospital failed to ensure the nursing care of each patient was assigned to other qualified nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available. This deficient practice was evidenced by 16 of 17 registered nurses having been assigned to work on an intensive care burn unit that accepts pediatric patients with no documented evidence of experience, education/training, skills/competencies for pediatric intensive care patients.

Findings:

Review of a document entitled, Plan for Providing Patient Care, revealed the following, in part: "Burn Center at Our Lady of Lourdes Regional Medical Center, Scope of Service: The purpose of the Burn Center is to coordinate and provide specialized burn care to patients with burn or like wounds, from admission through discharge. The Burn Center will consist of two parts: 1) an acute six-bed in patient intensive care unit and 2) an outpatient clinic. . . Clients of all ages, except for the neonate, will be serviced. Types of burn injuries that will be treated are those sustained from flames, chemicals, electrical shock, lengthening, smoke inhalation, chemical inhalation and/or carbon monoxide inhalation. II. Criteria for Entry/Admission to Service: Criteria as established by the American Burn Associated (ABA) for admission into the inpatient unit will be utilized. These include: partial thickness burns.10% of the total body surface area (TBSA); burns that involved the face, hands, feet, genitalia, perineum, and major joints; third degree burns in the appropriate age group; electrical burns, including lightening injury; chemical injury; burns involving inhalation injury; Burn injury in-patients with pre-existing medical disorders that could complicate management, prolong recover, or affect mortality; any age appropriate patient with burns and concomitant traumas (such as fractures or closed head injury) in which the burn injury poses the greatest risk of morbidity or mortality. In such cases, the trauma poses the greater immediate risk, the patient may be initially stabilized in a trauma center before being transferred to a burn unit. Physician judgment will be necessary in such situations and should be in concert with the regional medical control plan and triage protocols; burn injury that will require special social, emotional and/or long term rehabilitative intervention. The Burn Center at Our Lady of Lourdes RMC establishes the following qualifiers for pediatric patient admissions: admitted on a case by case basis-at the discretion of the medical director, or the physician on call for the Burn Center. I. Plan to Improve Quality of Care: . . . All staff who are at the point of contact with the patient who initially presents with the burn will receive Advanced Burn Life Support (ABLS) training. All RN staff with patient contact in the in-patient setting will maintain current Advanced Cardiac Life Support and Pediatric Advanced Life Support certifications.

Review of the document "Registered Nurse, (name of hospital) RMC 21LOU6495 Burn Center" job description revealed, in part, under the section "Specifications: Experience: Minimum Required, Preferred/Desired," blank spaces; "Training: Minimum Required, Preferred/Desired," blank spaces; under "Special Skills, Minimum Required": Proficient in the English language, verbal and written communication skills, computer skills."

Review of a Policy and Procedure "ICU Admission of a Pediatric Patient" revealed in part: "Policy: Define care of pediatric patient in ICU; Definitions: " All ICU patients will be cared for by RN ' s with established ICU competencies. "

In an interview on 07/05/16 at 11:15 a.m. during the entrance conference, S1Director confirmed there were two critical care units in the hospital which included an adult ICU and a Burn Unit. It was also confirmed the hospital did not provide pediatric services with the exception of the Burn Unit.

Review of the admission census to the Burn Unit for the past year revealed there was a pediatric patient (Patient #1) admitted to the Burn Unit who had been intubated in the ED and was ventilator dependent upon admission to the unit.

Patient #1
Review of the medical record for Patient #1 revealed he was an 8-year-old admitted to the Burn Unit on 05/15/16 and discharged on 06/06/16 by S20MD. Admitting diagnosis was second degree burns to head, neck, chest, and left upper extremities, covering approximately 6-8 % of Total Body Surface Area; Possible Inhalation Injury. Further review of the medical record revealed Patient #1 was extubated on 05/23/16.

In an interview on 07/06/16 at 10:30 a.m., S17Regulatory reviewed the medical record with surveyor and confirmed Patient #1 was cared for by S4RN, S6RN, S8RN, S9RN, S10RN, S11RN, S12RN, S13RN, S14RN, S15RN, S16RN, S19RN, S21RN, and S22RN during his hospital stay.

In an interview on 07/06/16 at 12:05 p.m. with S4RN, she said she had worked in the burn unit for two years. S4RN said she had no prior pediatric experience and she would not be comfortable with an unstable adolescent under 12 years old. She said PICU training like pediatric vent care, vital signs and ABG interpretations for pediatric patients would make her more feel more comfortable. S4RN said she did not think any of the staff would be comfortable taking care of an unstable pediatric patient.

Review of the personnel files for S4RN, S6RN, S8RN, S9RN, S10RN, S11RN, S12RN, S13RN, S14RN, S15RN, S16RN, S19RN, S21RN, and S22RN revealed no documented evidence that S4RN, S6RN, S8RN, S9RN, S10RN, S11RN, S12RN, S13RN, S14RN, S15RN, S16RN, S21RN, and S22RN had no pediatric-specific intensive care education, training, and/or experience in the PICU setting and did not have any documented evidence of pediatric-specific intensive care skills and competencies.

In a telephone interview on 07/07/16 at 6:00 p.m., S6RN she indicated had no prior pediatric intensive care unit training, education, and/or experience prior to being employed on the Burn Unit. She also indicated she had called in to cancel her shift assignment because she knew there was a pediatric patient on the unit who was ventilator dependent, and she did not feel competent to provide care to the patient. She also indicated other co-workers had expressed concern over the lack of training for providing care to pediatric patients who were ventilator-dependent. S6RN confirmed she had not received pediatric-specific training for intubated pediatric patients who were on ventilators.

In a telephone interview on 07/07/16 at 5:15 p.m., S8RN indicated she had some prior pediatric experience, but no PICU experience, and she was not comfortable taking care of critically ill pediatric patients who were ventilator dependent. She also indicated several of her co-workers had been expressing concern about the Burn Unit accepting critically ill, ventilator-dependent pediatric patients due to the lack of training and experience in taking care of these types of patients. S8RN confirmed she had not received pediatric-specific training for intubated pediatric patients who were on ventilators.

In a telephone interview on 07/07/16 at 8:00 a.m. with S12RN, she indicated she had not had any pediatric-specific intensive care education, training, and/or experience in the PICU setting prior to being employed on the Burn Unit. S12RN confirmed she had not received any pediatric-specific intensive care training and/or education for critically ill, ventilator-dependent pediatric patients after employment on the Burn Unit, and she would not be comfortable or feel competent to take care of younger pediatric patients, such as infants, toddlers, and pre-school aged children who were ventilator-dependent.

In a telephone interview on 07/07/16 at 8:45 a.m., S16RN indicated she had not had any pediatric-specific intensive care education, training, and/or experience in the PICU setting prior to being employed on the Burn Unit. She indicated she had some pediatric training and burn unit training, but confirmed she had not had any formal pediatric-specific intensive care education and/or training, and she was not comfortable providing care to critically ill pediatric patients who were ventilator dependent.

In an interview on 07/07/16 at 10:00 a.m. with S20MD, he said he was the medical director of the burn unit for approximately four years and co-director since opening in November 2009. He said the burn unit could accept any burn patient that met criteria per the American Burn Association and per hospital admission criteria. S20MD verified the hospital admission criteria was above a neonate (28 days old) but he made the ultimate decision on admissions. S20MD said he was not over the burn unit's nurse's training and was not in the nurse's chain of command. S20MD said he was not sure of the extent of the nurse's PICU training.

In an interview on 07/06/16 at 10:38 a.m., S1Director stated, when questioned about the vagueness of the competencies listed, if nurses required any information about nursing care and/or procedures for pediatric patients, nurses had the capability to use the on-line "Lippincott Procedures" as a resource for information needed to care for pediatric and/or pediatric intensive care patients.

Review of the personnel file for S2Manager revealed she had no documented evidence of pediatric intensive care experience, education/training, and skills/competencies prior to employment on the Burn Unit.

In an interview on 07/06/16 at 2:00 p.m. S2Manager indicated she had been the manager on the Burn Unit for about 2 years, and prior to that, she had worked as a staff nurse on the Burn Unit. S2Manager indicated all of the RNs working on the Burn Unit were required to have PALS certification, and, therefore, they were deemed competent to care for pediatric and/or pediatric patients requiring intensive care. S2Manager confirmed many of the staff nurses on the Burn Unit had expressed their discomfort with the care of pediatric patients due to their lack of experience and/or training, especially with the pediatric critical care patients. S2Manager indicated she had been looking into PICU courses for the nursing staff to take for about a year, but, as of yet, she had not scheduled any PICU training courses for the nursing staff.



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