HospitalInspections.org

Based on staff interview and review of Administrative documents, the Critical Access Hospital (CAH) failed to ensure that 1 of 5 diagnostic imaging services provided through contract, utilized technical staff that were licensed as Medical Radiographers as required by the State of Nebraska (bone density). Review of the Summary of Hospital Services, which was part of the Annual Evaluation dated 9/15/09 revealed 94 bone density tests were performed from August 2008 through September 2009. Findings are:

A. During review of Radiology Services on 9/20/10 from 1:00 PM to 2:10 PM the Imaging Supervisor was not able to provide evidence that the individual completing the bone density tests was licensed in the State of Nebraska as a Medical Radiographer. Interview on 9/20/10 at 2:55 PM with the Imaging Supervisor revealed the following:
- The medical radiographer license for the individual doing the bone density tests expired on 7/31/10;
- The license was still expired at the time of this interview;
- This individual had been to the CAH in August and September 2010 and had done a total of 12 bone density tests; and
- There was no system in place to ensure that individuals providing services through contract had current licenses as medical radiographers if required.

B. Review of the scheduling book for contracted imaging services confirmed that 9 bone density tests were performed on 8/9/10 and 3 bone density tests were performed on 9/7/10 for a total of 12.

C. Review of the Service Agreement for bone density tests with an effective date of 12/5/07 revealed the only reference to the individual providing the service was under the section titled Equipment. The section documented that the contracted service was responsible for providing "...supplies, equipment and technical expertise to perform each study." The contract lacked any requirement for ensuring current licensure of the person providing the "technical expertise".

Based on inpatient record reviews, staff interviews and review of facility policies and procedures, the facility failed to ensure a Registered Nurse (RN) supervised and evaluated the nursing care for 1 of 10 inpatients prior to delegation of nursing care to an Licensed Practical Nurse-Certified. Facility census was 10 plus 1 newborn. Total sample size was 44.
Findings are:

A. Record review revealed Patient 12, a current inpatient, was a direct to the nursing unit admit on 9/20/10 at 12:10 PM. Diagnoses included pneumonia of the left lung and history of stroke. The patient's care on admission was provided by a Licensed Practical Nurse-Certified (LPN-C) "A". LPN-C "A" performed and documented the assessment and care of Patient 12 beginning at 12:10 PM. The assessment noted the patient has poor skin turgor, was anxious and had pain in the upper chest with deep breaths. The LPN-C started an Intravenous (IV) of Normal Saline and began infusion at 100 cubic centimeters (cc) per hour. The LPN-C also noted the patient's lungs were slightly coarse with wheezes in the upper lobes and diminished in the lower lobes. The patient had a harsh cough that was productive of bloody-tinged sputum. The LPN-C documented the patient's respiratory effort was slightly labored at times. Oxygen saturation was 92-93% on room air. 95-100 % oxygen saturation is considered normal on room air. Oxygen was initiated at 2 liters per physician orders. Blood cultures were obtained and IV antibiotics were initiated. The respiratory therapist initiated orders for a respiratory aerosol treatment at 1:00 PM noting the patient's oxygen saturation was low at 89%. RN "B" documented an initial RN assessment/evaluation of the patient response to care at 3:30 PM (3 hours and 10 minutes after the patient's arrival). Prior to that, all nursing care/assessment was delegated to and provided by LPN-C "A". RN "B" documented the patient's medical doctor (MD) "C" came to evaluate the patient at 3:30 PM.

B. Interview with the Director of Nursing (DON) on 9/21/10 at 2:10 PM stated that the RN is to do the "hands on" assessment of the patient including assessment of the patient's pulmonary status including lung sounds, cardiovascular status with heart sounds and assessment of edema and gastrointestinal assessment including bowel sounds. The RN also completes an assessment related to the patient's chief complaint or diagnosis on admission. The DON related that their policy for assessments in the Emergency Department (ED) include an initial RN evaluation prior to delegation of patient care to an LPN or LPN-C but that was not done for inpatient admissions.

C. Interview with RN "B" on 9/23/10 at 10:35 AM revealed that the RN is to evaluate a new admit within the first hour of admission. RN "B" confirmed only seeing the patient in the hall before being needed in the Emergency Room. The nurse stated "The patient arrived with physician orders in hand." The patient had come from MD "C's" office to the hospital. RN "B" related that MD "C" was also in the ED with her. RN "B" related the 2 other on duty RN's were busy with other patients.

D. Record review of facility policy titled "Patient Assessments" dated 7/20/10 related to section titled "Patient admitted to the Med-surg [Medical-Surgical] floor in Acute Care (Inpatients)/Observation or Swing bed status: " states "All patients admitted onto the med-surg unit will receive a comprehensive assessment within 4 hours of admission." Regarding the LPN/LPN-C role the policy states they "may contribute to the assessment by collecting basic objective data from observation, examinations, interviews and a review of the health record. The policy fails to ensure a new admit is seen and evaluated by an RN prior to delegation of care to a LPN/LPN-C.

Based on review of medical records, staff interviews and facility policy and procedures, the facility failed to ensure the medical record included the documentation of the provision of nursing care and administration of medications for 3 of 3 sampled patients receiving cystoscopies in the Outpatient Specialty Clinic. Total sample included 44 patient records. Facility inpatient census was 10 plus 1 newborn. Findings are:

A. Record review of Outpatient Urology Clinic record dated 8/2/10 revealed a cystoscopy report by the urologist of a cystoscopy under local anesthesia. The report revealed Patient 38 was prepped and draped. Local anesthesia of "Xylocaine jelly" was inserted in the urethra. Record review of facility document titled "Operative Record" contains only BP, Respirations, Pulse Oxygen saturations and times starting at 8:30 AM and ending at 8:50 AM. The record documents "start 0840" and "stop 0843." Preop BP was normal at 130/77. The patient was hypertensive during the procedure with a high blood pressure of 200/97 recorded at 8:41 AM, 185/88 at 8:44 AM and 160/75 at 8:50 AM post procedure. The record of vital signs is signed by the urologist. The record lacks evidence of documentation by nursing. A Registered Nurse (RN) signature appears only on the consent form as a witness to the patient's consent.

B. Record review of Outpatient Urology Clinic record dated 8/2/10 revealed a cystoscopy report by the urologist for a cystoscopy under local anesthesia. The report revealed Patient 39 was prepped and draped. Local anesthesia of "Lidocaine jelly was inserted into the urethra." The urologist noted the patient was provided a prescription for a medication and was to have a follow-up cystoscopy in 6 months. Record review of facility document titled "Operative Record" contained stable vital signs and oxygen saturations starting at 11:08 AM and ending at 11:24 AM. "Start 1116, stop 11:20" is documented. The record is signed by the urologist. The record lacks documentation by nursing. A RN signature appears only on the consent form as a witness to the patient's consent.

C. Record review of Outpatient Urology Clinic record dated 8/19/10 revealed Patient 40 had a cystoscopy under local anesthesia. The urologist completed an "Operation Record" noting the patient was "sterilely prepped and draped." There is no mention in the record of what medication was used for the local anesthesia. Review of the facility "Operative Record" notes vital signs and oxygen saturations from 8:10-8:27 AM. The patient's oxygen saturations were low, normal is 95-100% on room air. Preop at 8:10 AM the patient was 91%. At 8:25 AM and 8:27 AM the patient was at 89%. The record notes the patient is to have a followup appointment at 3 months for another cystoscopy. The records are signed by the urologist and lack any documentation by nursing. The surgical consent contains the signature of Licensed Practical Nurse (LPN)-D's signature as a witness.

D. Staff interview with LPN-D on 9/22/10 at 4:45 PM revealed LPN-D assists urologists in the clinic during cystoscopies. LPN-D functions as a Specialty Clinic Nurse.

E. Staff interview with the Outpatient Specialty Clinic supervisor related that the clinic is staffed with RNs and LPNs. The supervisor reviewed the records of Patients 38, 39 and 40 and confirmed there are no nursing notes or assessments for cystoscopies made by nursing. The supervisor confirmed the signature at the bottom of the Operative Records containing the patient's vital signs was that of the urologist and not a nurse. The facility has policies and procedures for both male and female cystoscopy but does not include nursing documentation.

F. Interview with the Director of Nursing (DON) on 9/23/10 at 10:55 AM confirmed nursing is not signing the documentation of the vital signs. Medications are not documented. The DON confirmed the facility has not included cystoscopy patients in any of their nursing documentation audits and was unaware of the lack of nursing documentation.

G. Review of facility policy titled "Male Cystoscope" and "Female Cystoscope" are dated 4/2001. The policies identify staff are to "check patient allergies prior to exam to note if patient is allergic to Betadine, xylocaine, or its derivatives." The polices further direct staff to obtain a full set of vitals and have the patient empty their bladder. Staff are directed to cleanse the patient's urethral area with Betadine and "Inject lidocaine jelly into urethral opening using a urojet." Vital signs are to be taken during and after the procedure. After the procedure the staff are to "give and review copy of Cystoscope Patient Information sheet with patient prior to discharge." The policy failed to mention any documentation is needed.