HospitalInspections.org

Based on record review, policy review and interview,the facility failed to ensure specialized nursing care was provided to patients by nursing staff who had current competency testing in the area of moderate sedation. As a result, patients were placed at risk of receiving services from nurses whose hand-on skill level was inadequate. Findings:


Record review on 12/10-11/12 of 11 patients (#s 1; 2; 3; 4; 5; 7; 8; 10; 11; 13; and 14) who received colonoscopies at the facility revealed registered nurses #s 2, 3, and 4 had provided moderate sedation during their colonoscopy procedures. Two of the registered nurses #s 3 & 4 had not received a competency check off since 11/2005.


Review of registered nurses #s 2, 3, and 4 education records revealed there were no current competency testing for the area of moderate sedation.


During an interview on 12/11/12 at 7:30 am the Assistant Administrator disclosed the facility had discontinued competency testing 3-4 years ago when the Providence hospital system had changed from competency testing to just ensuring continuing education was completed. When the surveyor asked how the facility ensured the staff were able to carry out the tasks that were in the past monitored by competency testing the Assistant Administrator disclosed they did not have a method for ensuring hands-on competencies.


Review of the facility's policy and procedure "Moderate and Deep sedation" dated 11/9/11, revealed "C. The RN assisting with sedation are required to: 1. Have current moderate and/or deep sedation competency-based sedation education."