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Based on interview, record review and review of the facility's Security Management Plan Policy, Assessment of Competencies Policy, Name Badges Policy, Scope of Activities of Volunteers Policy, Coordination of Volunteer Services Policy, Professional Image/Attire-General Policy, and Job Shadowing Policy, it was determined the facility failed to provide care in a safe setting. On 06/22/12, an individual arrived at the Emergency Department (ED), claimed to be a job shadowing participant and a volunteer, was given scrubs and shoe covers and allowed to be in patient care areas. On 06/23/12 the same individual, claimed to be a nursing assistant from another unit, was allowed to perform patient care in the ED and on the 3 North unit. On 06/24/12 the individual was allowed to perform patient care on the 3 North unit until the individual asked the Charge Nurse (CN) for a key to the Surgery Unit in order to get scrubs for a friend who was also going to volunteer. The individual worked in patient areas and performed patient care for three (3) days without any staff questioning who the individual was or if the individual was qualified to perform patient care. The facility failed to ensure the individual, posing as a "volunteer", provided care within the facility's "volunteer" scope of practice. This failure placed patients at risk for injury, harm, impairment or death. On 07/03/12, Immediate Jeopardy was determined to exist related to Patient Rights. The facility initiated corrective actions on 07/03/12.

Refer to A-144

AMENDED
A review by the Centers for Medicare & Medicaid Services (CMS) determined Immediate Jeopardy was ongoing at the time of the abbreviated survey.

Based on interview, record review and review of the facility's Security Management Plan Policy, Assessment of Competencies Policy, Name Badges Policy, Scope of Activities of Volunteers Policy, Coordination of Volunteer Services Policy, Professional Image/Attire-General Policy, and Job Shadowing Policy, it was determined the facility failed to provide care in a safe setting as evidenced by an individual, posing as a volunteer/job shadowing participant/nursing assistant, was allowed to provide direct patient care beyond a volunteer's or job shadowing participant's scope of practice.

AMENDED
A review by the Centers for Medicare & Medicaid Services (CMS) determined Immediate Jeopardy was ongoing at the time of the abbreviated survey.

The findings include:

Review of the facility's Scope of Activities of Volunteers Policy, effective 05/07/11, revealed volunteers must be identified and report to the nurse in charge. The role of individual volunteers may be limited by their knowledge, abilities, and skills and no volunteer would be permitted to perform tasks beyond their knowledge and skill. Further review revealed the nurse in charge maintained responsibility for care or assistance given by volunteers to patients as well as the direction of the volunteers.

Review of the facility's Coordination of Volunteer Services Policy, effective 10/21/09, revealed volunteers were to receive orientation, training and supervision from the St. Claire Regional (SCR) Volunteer Guild Group Director or designee regarding responsibilities to the Medical Center facilities and its patients. Further review revealed volunteers were issued an identification badge which was to be worn at all times while volunteering.

Review of the facility's Job Shadowing Policy, wffective 08/12/10, revealed St. Claire Regional acknowledged its primary responsibility was to maintain the health, confidentiality and comfort of each patient. Job shadowing participants were to complete an application for job shadowing, have a completed Health Screening Form, up-to date negative Tuberculosis Skin Test and immunization record and go through orientation prior to participation. All participants would have a SCR staff member appointed as their mentor, would be under the mentor's supervision at all times and would not be allowed unrestricted access at SCR or other SCR facilities. Further review revealed the participant would not be allowed direct patient contact which was defined as physically touching, performing an examination, conducting patient or family counseling, assisting in surgery or performing any other procedure with patients. All participants would adhere to all SCR policies and procedures including dress code, confidentiality and infection control and would wear the appropriate "Job Shadowing" identification visable at all times to SCR staff, visitors, patients, volunteers and medical staff.

Review of the facility's Name Badges Policy, revised 05/09/00, revealed SCR Medical Center was committed to a safe and secure environment for patients, staff and visitors and the primary reason for wearing a name badge was to identify the staff member to patients and visitors. All staff members, contract staff and volunteers would receive and wear Name Badges at all times while performing their duties at SCR.

Review of the facility's Professional Image/Attire-General Policy, revised 09/22/09, and the Security Management Plan Policy, revised 02/27/12, revealed staff and volunteers would wear name badges, in clear sight, at all times while performing their duties. The Security Management Plan Policy also stated the purpose of the policy was to maintain a security program that provided a safe, secure area for SCR Medical Center patients, visitors, staff, and properties. Access to the Emergency Department (ED) was to be controlled by keypads and only designated staff had the combination for the keypads. All other visitors or staff had to gain entry into the ED by ED personnel.

Review of the facility's Assessment of Competencies Policy, effective 09/10/97, revealed the purpose of the policy was to ensure patients were managed by competent nursing staff described as Registered Nurses (RN), Licensed Practical Nurses and Nursing Assistants, with routine and specialized knowledge and skills to provide for the needs of the patients. Nursing personnel were to have their competency assessed as part of initial employment and orientation. Further review revealed when nursing staff were "floated/pulled" (work in a different unit than they normally work in) they were expected to perform only those duties for which they were currently competent. It was the responsibility of the nurse or nursing assistant to determine which duties the "floater" was competent to perform.

Interview, on 07/02/12 at 2:55 PM, with Housekeeper #5 revealed the individual arrived in the ED through the Radiology doors (which were never locked) and told the housekeeper the college was paying them to volunteer. The housekeeper took the individual to the ED CN. Further interview revealed the ED CN gave the "volunteer" scrubs to wear. The housekeeper stated she saw the "volunteer" following the Physician (MD) and Nurses (shadowing them). The housekeeper stated she asked the Physician's Assistant (PA) "Wouldn't it be funny if she's not from the college?". The housekeeper alleged the PA had stated it would be like writing a paper on how easy it is to perform patient care without qualifications.

Interview, on 07/03/12 at 8:10 AM with Registered Nurse (RN) #1, revealed she was the ED CN on 06/22/12 and the housekeeper brought the "volunteer" to her. She stated the individual told her, she was a college student and was volunteering for credit hours. The "volunteer" followed the MD most of the time until ED had a patient who needed a blood transfusion and the individual was interested in that patient. The patient was sent to the Intensive Care Unit (ICU) and she didn't know if the "volunteer" went to the ICU with the patient or not; however, she didn't see the "volunteer" after that. Further interview revealed the CN did not see the "volunteer" touch any patients or in any patient rooms by themself; however, she did see the "volunteer" talk to patients in a nice, professional manner. Still further interview revealed the CN did not ask to see any identification; however, she should have. The procedure was to call the Coordinator if no name badge was visible. Prior to the incident, the procedure was staff wrote their names in a log, if they didn't have their badge. After the incident, the policy changed to staff had to wear their badge and could not work until they got it.

Interview, on 07/02/12 at 11:40 AM, with RN #2 revealed she was the ED CN on 06/23/12 and the individual told her she was shadowing for a couple days and was in a NA course. Further interview revealed the "shadowing participant" was wearing scrubs and a lab jacket, knew their way around the ED and acted normal. She stated the individual helped the triage nurse take vital signs by placing the blood pressure cuff on the patient and pushed a button. Further interview revealed the individual wanted to chart in a patient's chart and the CN told her that wasn't allowed. She stated the individual requested the CN give them reports on patients so the individual could start performing NA duties. The CN stated she told the individual she did not normally do that and the individual called 3 North and left the ED to help 3 North. The CN stated the ED did not use volunteers but the individual told her they were shadowing and the ED did have students who shadow the nurses or MD.

Interview, on 07/03/12 at 9:50 AM, with RN #5 revealed she was the Triage Nurse in the ED on 06/23/12 and the CN brought an individual, from the 4th floor to assist her in the triage room. Continued interview revealed the individual stated it was their second day in the ED and she wanted to do charting but the RN told her that was the nurses responsibility. Further interview revealed the individual took patients' blood pressures and oxygen saturations. The RN said she had to show the individual how to put the cuff on five (5) times; however, she didn't think anything of that because different floors have different equipment. The RN didn't recall the individual being alone with patients or if they were wearing a name badge, did recall they were wearing blue scrubs. She stated staff were supposed to wear name badges; however, people do forget to wear them. She also stated, if she saw someone new, she would ask who they were; however, the individual was brought to her and she was told they were supposed to work.

Interview, on 07/02/12 at 12:05 PM, with RN #6 revealed she worked in the ED on Saturday, 06/23/12 (usually works on 3N) and saw the individual talking with staff like she knew them. She thought the individual worked in the ED. Further interview revealed the individual worked on 3N on Sunday, 06/24/12, told her that they were in nursing school and could do vitals. The individual asked the CN for scrubs for a friend, who had arrived and also wanted to volunteer. The CN had the individual stay at the desk while she called the Nursing Coordinator. The individual stated Human Resources had not made their name badge yet.

Interview, on 07/03/12 at 2:00 PM, with RN #3 revealed she was the CN on 3N on 06/23/12. Further interview revealed the individual came to the floor and told her the ED sent her to help on 3N. She didn't ask to see identification nor could she recall if they individual was wearing a name badge. The individual stated they were a nursing student and asked what needed to be done. The individual helped the NA perform direct patient care. Further interview revealed the correct procedure for "floaters" was the Nurse Coordinator should call the CN to tell them help was coming; however, that didn't happen and she did not verify the NC or ED sent the individual to help nor did she call security. She further stated the CN was not responsible for the safety of the patients, each nurse was responsible. The CN stated she directed traffic, ran the routine of the floor and completed paperwork and that each nurse had their own patients and was accountable for their assignments. She also stated she was not responsible for what happened, she could not help it if someone sent a volunteer to help the aides, it was not her job to fix problems. She eventually said she should have verified the person was who they said they were.

Interview, on 06/29/12 at 3:30 PM, with the Nursing Coordinator (NC) revealed she was notified, by the CN on 3N on 06/24/12, that a "volunteer" was requesting scrubs for a friend, who was also going to volunteer. The "volunteer" did not have a name badge, identification, or paperwork and was wearing what looked like SCR scrubs. She stated she told the CN to detain the individual while she called the Chief Nursing Officer (CNO). The CNO stated no volunteers were expected and to escort the "volunteer" to the door. The NC followed the individual to the lounge and the individual entered the code to the lounge. The NC did not know how the individual got the code or the scrubs. Further interview revealed the "volunteer" said she was a nursing student and wanted experience and was told, by the Director of Volunteer Services (DVS), they could volunteer anywhere in the hospital. The NC spoke with the staff on 3N and was told the volunteer worked on 3N and in the ED on 06/23/12. The NC spoke with the CN in the ED and was told the "volunteer" helped the Triage Nurse on 06/23/12.

Interview, on 07/02/12 at 2:22 PM, with the Director of Critical Care Services revealed the individual told the CN she was a student at the college, was there to shadow staff and the CN gave the scrubs to the individual. He stated he wasn't sure what the individual did other than help the Triage Nurse with vital signs by putting the BP cuff on a patient and pushed a button. The VS were charted by the nurse, not the individual. He also stated he was unsure if anyone asked what certification the individual had. Further interview revealed the individual left the ED to assist on another floor.

Interview, on 07/02/12 at 8:30 AM, with the Chief Nursing Officer (CNO) revealed NC called her, stated a "volunteer" was on 3N and asked the CN for keys to Surgery Unit, to get scrubs for a friend who was also going to "volunteer". The CNO told the NC to escort both individuals to the door. The "volunteer" knew the codes to the nursing lounge, ED and the ICU. Further interview revealed the individual worked in the ED and 3N, and attempted to work in the ICU; however, the individual was told the ICU didn't need help. Interview, on 07/5/12 at 10:45 AM, revealed the individual shadowed the MD in the ED on 06/22/12 and 06/23/12, took VS for the Triage Nurse, and then worked on 3N. On 06/24/12 the "volunteer" worked on 3N again until the friend arrived. Additional interview, on 07/06/12 at 11:45 AM, reveealed the individual observed labs being drawn in the lab and the ED; however did not touch patients or the equipment and didn't observe a blood transfusion. Further interview revealed the "volunteer" performed direct patient care. Interview, on 07/06/12 at 3:00 PM, revealed the nurses should have inquired if they could help the stranger, asked for ID and called the NC.

Interview, on 6/29/12 at 5:00 PM, with the facility's Risk and Compliance Manager revealed an individual wore scrubs with the hospital's logo and asked for the code to sugery to get scrubs for their friend. Interview, on 07/02/12 at 5:00 PM, revealed the Director of Facilities and Security reviewed video to determine what happened and it showed the housekeeper approached the individual and the housekeeper took them to the CN. Further interview revealed the individual told the CN she was a "volunteer" and was told by the Director of Volunteer Services they could come to volunteer anytime because their background check came back clean. The CN gave the "volunteer" scrubs and shoe covers to wear. The individual worked on 06/22/12, 06/23/12, and 06/24/12. Suspicion arose when the "volunteer" brought a friend with them to "volunteer".

The facility failed to ensure the individual, posing as a "volunteer", provided care within the facility "volunteer" scope of practice. This failure placed patients at risk for injury, harm, impairment or death. Immediate Jeopardy was determined to exist related to Patient Rights. The facility initiated corrective actions on 07/03/12. Patient Safety inservice was mandatory for all hospital employees, prior to their next shift. Patient safety and security education was added orientation and annual competency. Managers and Charge Nurses would monitor badge compliance daily and staff would not be allowed to work with their badge. A dedicated phone number for Security was added, to ensure immediate response. The doors, the individual used to gain access to the ED, were locked and designated as an exit.

Based on interview, record review and review of the facility's Assessment of Competencies Policy, Name Badges Policy, Scope of Activities of Volunteers Policy, Coordination of Volunteer Services Policy, and Job Shadowing Policy, it was determined the facility failed to provide competent nursing personnel. An individual, posed as a job shadowing participant, a volunteer, a college student and a Nursing Assistant from another unit in the facility, was given scrubs and shoe covers and allowed to be in patient care areas and provide direct patient care without any facility staff questioning their competency, qualifications or identification (ID). The facility allowed the individual to perform direct patient care in the Emergency Department (ED) and the 3 North (3N) Unit for three (3) days before the facility became aware of the situation. The facility failed to ensure the individual, posing as a "volunteer" and "job shadowing participant", provided care within the facility "volunteer" scope of practice. This failure placed patients at risk for injury, harm, impairment or death. Immediate Jeopardy was determined to exist, on 07/03/12, related to Nursing Services. The facility initiated corrective action on 07/03/12. Those actions were as follows: every employee was required to have a patient safety inservice prior to their next shift, new employee orientation and annual competency was revised to include patient safety and security. Department leaders were to make daily rounds to ensure employees were compliant with wearing their name badge. The Security Management Plan was revised and a phone number was assigned to Security to ensure rapid response. The doors the individual used to go into the ED, were changed to exit only and were locked.

AMENDED
A review by the Centers for Medicare & Medicaid Services (CMS) determined Immediate Jeopardy was ongoing at the time of the abbreviated survey.

Based on interview and record review, it was determined the facility failed to ensure patients were properly and adequately informed of discharge instructions for one (1) of ten (10) sampled patients (Patient #5). Patient #5 was admitted, on 06/25/12, with diagnoses which included Anxiety, Bipolar Disorder, Panic Attack and Coronary Artery Disease. The patient was discharged, on 06/26/12, without being informed of discharge instructions and Physician appointments (verbal or written).

The findings include:

Record review revealed the facility admitted Patient #5, on 06/25/12, with diagnoses which included Anxiety, Bipolar Disorder, Panic Attack, and Coronary Artery Disease .

Record Review revealed Patient #5 was discharged, on 06/26/12, with no documented evidence the patient received the Discharge Information Form, the Patient Visit Information Form or the Final Discharge Medications List. The Discharge Form instructed patients with information they would need (regarding phone numbers they may need and diet information). The Patient Visit form informed patients of follow up appointments or when the patient needed to make the appointments. The Medications List informed patients of medications they were to take.

Interview, on 07/05/12 at 11:20 AM, with the Nurse Manager of the 3 North Unit revealed she could not find documented evidence the nurse gave Patient #5 discharge instructions. The patient did not sign the discharge papers, that were supposed to be done when they were given the instructions.

Interview, on 07/05/12 at 10:45 AM, with the Chief Nursing Officer (CNO) revealed the nurse failed to document that she gave the patient verbal or written instructions. All patients were to receive verbal and written instructions.

Based on interview, record review and review of the facility's Assessment of Competencies Policy, Scope of Activities of Volunteers Policy, Coordination of Volunteer Services Policy, Job Shadowing Policy and Name Badges Policy it was determined the facility failed to provide competent nursing personnel. An individual, posed as a job shadowing participant, a volunteer, a college student and a "Nurses Assistant from another unit in the facility", was given scrubs and shoe covers and allowed to be in patient care areas and provided direct patient care without any facility staff questioning their competency, qualifications or identification (ID). The facility allowed the individual to perform direct patient care in the Emergency Department (ED) and the 3North (3N) Unit for three (3) days. The facility failed to ensure the individual, posing as a "volunteer" and a "job shadowing participant", provided care within the facility's "volunteer" and "job shadowing" scope of practice. This failure placed patients at risk for injury, harm, impairment or death. Immediate Jeopardy was determined to exist, on 07/03/12, related to Patient Rights and Nursing Services. The facility initiated corrective actions, on 07/03/12.

AMENDED
A review by the Centers for Medicare and Medicaid (CMS) determined Immediate Jeopardy was ongoing at the time of the abbreviated survey.

The findings include:

Review of the facility's Assessment of Competencies Policy, effective 09/10/97, revealed the purpose of the policy was to ensure patients were managed by competent nursing staff described as Registered Nurses (RN), Licensed Practical Nurses (LPN) and Nursing Assistants (NA), with routine and specialized knowledge and skills to provide for the needs of the patients. Nursing personnel were to have their competency assessed as part of initial employment and orientation. Further review revealed when nursing staff were "floated/pulled" (work in different unit than they normally work in) they were expected to perform only those duties for which they were currently competent. It was the responsibility of the nurse or nursing assistant to determine which duties the "floater" was competent to perform.

Review of the facility's Scope of Activities of Volunteers Policy, effective 05/07/11, revealed the nurse in charge was responsible for the care volunteers provided to the patients. The role of volunteers was limited by their knowledge, abilities, and skills and no volunteer would be permitted to perform tasks beyond their knowledge and skill.

Review of the facility's Coordination of Volunteer Services Policy, effective 10/21/09, revealed volunteers were to receive orientation, training and supervision from the Director of Volunteer Services regarding the volunteer's responsibilities to the Medical Center and the patients. Volunteers were issued an identification badge which was to be worn at all times while volunteering.

Review of the Job Shadowing Policy, effective 08/12/10, revealed St. Claire Regional acknowledged it's primary responsibility was to maintain the health, confidentiality and comfort of each patient. Job shadowing participants were to go through orientation prior to participation and would wear a name badge at all times. All participants would be under a mentor's supervision at all times and would not be allowed unrestricted access at the facility. Further review revealed the participant would not be allowed direct patient contact which was defined as physically touching, performing an examination, conducting patient or family counseling, assisting in surgery or performing any other procedure with patients.

Review of the Name Badges Policy, revised 05/09/00, revealed the primary reason for wearing a name badge was to identify the staff member to patients and visitors. All staff members, contract staff and volunteers were to receive and wear Name Badges at all times while performing their duties at SCR.

Interview, on 07/02/12 at 2:55 PM, with the Housekeeper #5 revealed the individual arrived in the ED through the Radiology doors (which were never locked) and told the housekeeper that the college was paying them to volunteer. The housekeeper took the individual to the ED Charge Nurse (CN). Further interview revealed the ED CN gave the "volunteer" scrubs to wear. The housekeeper stated she saw the "volunteer" following the Physician (MD) and Nurses (shadowing them). The housekeeper stated she asked the Physician's Assistant (PA) "Wouldn't it be funny if she's not from the college?". The housekeeper alleged the PA stated it would be like writing a paper on how easy it is to perform patient care without qualifications.

Interview, on 07/03/12 at 8:10 AM, with Registered Nurse (RN) #1, revealed she was the CN in the ED on 06/22/12 and the housekeeper brought the "volunteer" to her. She stated the individual told her, she was a college student and was volunteering for credit. Further interview revealed the CN did not ask to see any identification; however, she should have. The procedure was to call the Coordinator if no name badge was visible. Prior to the incident, the procedure was staff would write their names in a log, if they didn't have their badge. After the incident, the policy changed to staff had to wear their badge and could not work until they received it.

Interview, on 07/02/12 at 11:40 AM, with RN #2 revealed she was the ED CN on 06/23/12 and the individual told her she was shadowing for a couple days and was in a NA course. The "shadowing participant" was wearing scrubs and a lab jacket, knew their way around the ED and acted normal. The individual helped the triage nurse take vital signs by placing the blood pressure cuff on a patient and pushed a button. Further interview revealed the individual wanted to chart in a patient's chart and the CN told her that wasn't allowed. The individual requested the CN give her a report on patients so the individual could start performing NA duties. The CN stated she told the individual she didn't normally do that and the individual called 3 North and left the ED to help 3 North. The CN stated the ED did not use volunteers but the individual told her they were shadowing and the ED did have students who shadow the nurses or MD.


Interview, on 07/03/12 at 9:50 AM, with RN #5 revealed she was the Triage Nurse in the ED on 06/23/12 and the CN brought an individual, from the 4th floor to assist her in the triage room. The individual stated it was her second day in the ED and she wanted to do charting but the RN told her that was the nurses responsibility. Further interview revealed the individual took a patient's blood pressure and oxygen saturation. The RN said she had to show the individual how to put the cuff on five (5) times; however, she didn't think anything of that because different floors have different equipment. She also stated, if she saw someone new, she would ask who they were; however, the individual was brought to her and she was told they were supposed to work.


Interview, on 07/03/12 at 2:00 PM, with RN #3 revealed she was the CN on 3N on 06/23/12, when the individual came to the floor and told her the ED sent her to help on 3N. She didn't ask to see identification nor could she recall if the individual was wearing a name badge. The individual stated she was a nursing student and asked what needed to be done. The individual helped the NA perform direct patient care. Further interview revealed the correct procedure for "floaters" was the Nurse Coordinator should call the CN to let them know help was coming; however, that didn't happen. She did not verify, with the NC or ED, if they sent the individual to help nor did she call security. She also stated she was not responsible for what happened, she could not help it if someone sent a volunteer to help the aides, it was not her job to fix problems. She said she should have verified the person was who they said they were.

Interview, on 07/02/12 at 2:22 PM, with the Director of Critical Care Services revealed the individual told the CN she was a student at the college, was there to shadow staff and the CN gave the scrubs to the individual. He wasn't sure what the individual did other than help the Triage Nurse with vital signs by putting the BP cuff on a patient and pushed a button. The VS were charted by the nurse, not the individual. He also stated he was unsure if anyone asked what certification the individual had. Further interview revealed the individual left the ED to assist on another floor.

Interview, on 07/06/12 at 3:00 PM, with the Chief Nursing Officer revealed the nurses should have inquired if they could help the stranger, asked for ID and called the NC.

Based on interview, record review and review of the facility's Security Management Plan Policy, Assessment of Competencies Policy, Name Badges Policy, Scope of Activities of Volunteers Policy, Coordination of Volunteer Services Policy, Professional Image/Attire-General Policy, and Job Shadowing Policy, it was determined the facility failed to provide care in a safe setting as evidenced by an individual, posing as a volunteer/job shadowing participant/nursing assistant, was allowed to provide direct patient care beyond a volunteer's or job shadowing participant's scope of practice.

AMENDED
A review by the Centers for Medicare & Medicaid Services (CMS) determined Immediate Jeopardy was ongoing at the time of the abbreviated survey.

The findings include:

Review of the facility's Scope of Activities of Volunteers Policy, effective 05/07/11, revealed volunteers must be identified and report to the nurse in charge. The role of individual volunteers may be limited by their knowledge, abilities, and skills and no volunteer would be permitted to perform tasks beyond their knowledge and skill. Further review revealed the nurse in charge maintained responsibility for care or assistance given by volunteers to patients as well as the direction of the volunteers.

Review of the facility's Coordination of Volunteer Services Policy, effective 10/21/09, revealed volunteers were to receive orientation, training and supervision from the St. Claire Regional (SCR) Volunteer Guild Group Director or designee regarding responsibilities to the Medical Center facilities and its patients. Further review revealed volunteers were issued an identification badge which was to be worn at all times while volunteering.

Review of the facility's Job Shadowing Policy, wffective 08/12/10, revealed St. Claire Regional acknowledged its primary responsibility was to maintain the health, confidentiality and comfort of each patient. Job shadowing participants were to complete an application for job shadowing, have a completed Health Screening Form, up-to date negative Tuberculosis Skin Test and immunization record and go through orientation prior to participation. All participants would have a SCR staff member appointed as their mentor, would be under the mentor's supervision at all times and would not be allowed unrestricted access at SCR or other SCR facilities. Further review revealed the participant would not be allowed direct patient contact which was defined as physically touching, performing an examination, conducting patient or family counseling, assisting in surgery or performing any other procedure with patients. All participants would adhere to all SCR policies and procedures including dress code, confidentiality and infection control and would wear the appropriate "Job Shadowing" identification visable at all times to SCR staff, visitors, patients, volunteers and medical staff.

Review of the facility's Name Badges Policy, revised 05/09/00, revealed SCR Medical Center was committed to a safe and secure environment for patients, staff and visitors and the primary reason for wearing a name badge was to identify the staff member to patients and visitors. All staff members, contract staff and volunteers would receive and wear Name Badges at all times while performing their duties at SCR.

Review of the facility's Professional Image/Attire-General Policy, revised 09/22/09, and the Security Management Plan Policy, revised 02/27/12, revealed staff and volunteers would wear name badges, in clear sight, at all times while performing their duties. The Security Management Plan Policy also stated the purpose of the policy was to maintain a security program that provided a safe, secure area for SCR Medical Center patients, visitors, staff, and properties. Access to the Emergency Department (ED) was to be controlled by keypads and only designated staff had the combination for the keypads. All other visitors or staff had to gain entry into the ED by ED personnel.

Review of the facility's Assessment of Competencies Policy, effective 09/10/97, revealed the purpose of the policy was to ensure patients were managed by competent nursing staff described as Registered Nurses (RN), Licensed Practical Nurses and Nursing Assistants, with routine and specialized knowledge and skills to provide for the needs of the patients. Nursing personnel were to have their competency assessed as part of initial employment and orientation. Further review revealed when nursing staff were "floated/pulled" (work in a different unit than they normally work in) they were expected to perform only those duties for which they were currently competent. It was the responsibility of the nurse or nursing assistant to determine which duties the "floater" was competent to perform.

Interview, on 07/02/12 at 2:55 PM, with Housekeeper #5 revealed the individual arrived in the ED through the Radiology doors (which were never locked) and told the housekeeper the college was paying them to volunteer. The housekeeper took the individual to the ED CN. Further interview revealed the ED CN gave the "volunteer" scrubs to wear. The housekeeper stated she saw the "volunteer" following the Physician (MD) and Nurses (shadowing them). The housekeeper stated she asked the Physician's Assistant (PA) "Wouldn't it be funny if she's not from the college?". The housekeeper alleged the PA had stated it would be like writing a paper on how easy it is to perform patient care without qualifications.

Interview, on 07/03/12 at 8:10 AM with Registered Nurse (RN) #1, revealed she was the ED CN on 06/22/12 and the housekeeper brought the "volunteer" to her. She stated the individual told her, she was a college student and was volunteering for credit hours. The "volunteer" followed the MD most of the time until ED had a patient who needed a blood transfusion and the individual was interested in that patient. The patient was sent to the Intensive Care Unit (ICU) and she didn't know if the "volunteer" went to the ICU with the patient or not; however, she didn't see the "volunteer" after that. Further interview revealed the CN did not see the "volunteer" touch any patients or in any patient rooms by themself; however, she did see the "volunteer" talk to patients in a nice, professional manner. Still further interview revealed the CN did not ask to see any identification; however, she should have. The procedure was to call the Coordinator if no name badge was visible. Prior to the incident, the procedure was staff wrote their names in a log, if they didn't have their badge. After the incident, the policy changed to staff had to wear their badge and could not work until they got it.

Interview, on 07/02/12 at 11:40 AM, with RN #2 revealed she was the ED CN on 06/23/12 and the individual told her she was shadowing for a couple days and was in a NA course. Further interview revealed the "shadowing participant" was wearing scrubs and a lab jacket, knew their way around the ED and acted normal. She stated the individual helped the triage nurse take vital signs by placing the blood pressure cuff on the patient and pushed a button. Further interview revealed the individual wanted to chart in a patient's chart and the CN told her that wasn't allowed. She stated the individual requested the CN give them reports on patients so the individual could start performing NA duties. The CN stated she told the individual she did not normally do that and the individual called 3 North and left the ED to help 3 North. The CN stated the ED did not use volunteers but the individual told her they were shadowing and the ED did have students who shadow the nurses or MD.

Interview, on 07/03/12 at 9:50 AM, with RN #5 revealed she was the Triage Nurse in the ED on 06/23/12 and the CN brought an individual, from the 4th floor to assist her in the triage room. Continued interview revealed the individual stated it was their second day in the ED and she wanted to do charting but the RN told her that was the nurses responsibility. Further interview revealed the individual took patients' blood pressures and oxygen saturations. The RN said she h

Based on interview, record review and review of the facility's Assessment of Competencies Policy, Scope of Activities of Volunteers Policy, Coordination of Volunteer Services Policy, Job Shadowing Policy and Name Badges Policy it was determined the facility failed to provide competent nursing personnel. An individual, posed as a job shadowing participant, a volunteer, a college student and a "Nurses Assistant from another unit in the facility", was given scrubs and shoe covers and allowed to be in patient care areas and provided direct patient care without any facility staff questioning their competency, qualifications or identification (ID). The facility allowed the individual to perform direct patient care in the Emergency Department (ED) and the 3North (3N) Unit for three (3) days. The facility failed to ensure the individual, posing as a "volunteer" and a "job shadowing participant", provided care within the facility's "volunteer" and "job shadowing" scope of practice. This failure placed patients at risk for injury, harm, impairment or death. Immediate Jeopardy was determined to exist, on 07/03/12, related to Patient Rights and Nursing Services. The facility initiated corrective actions, on 07/03/12.

AMENDED
A review by the Centers for Medicare and Medicaid (CMS) determined Immediate Jeopardy was ongoing at the time of the abbreviated survey.

The findings include:

Review of the facility's Assessment of Competencies Policy, effective 09/10/97, revealed the purpose of the policy was to ensure patients were managed by competent nursing staff described as Registered Nurses (RN), Licensed Practical Nurses (LPN) and Nursing Assistants (NA), with routine and specialized knowledge and skills to provide for the needs of the patients. Nursing personnel were to have their competency assessed as part of initial employment and orientation. Further review revealed when nursing staff were "floated/pulled" (work in different unit than they normally work in) they were expected to perform only those duties for which they were currently competent. It was the responsibility of the nurse or nursing assistant to determine which duties the "floater" was competent to perform.

Review of the facility's Scope of Activities of Volunteers Policy, effective 05/07/11, revealed the nurse in charge was responsible for the care volunteers provided to the patients. The role of volunteers was limited by their knowledge, abilities, and skills and no volunteer would be permitted to perform tasks beyond their knowledge and skill.

Review of the facility's Coordination of Volunteer Services Policy, effective 10/21/09, revealed volunteers were to receive orientation, training and supervision from the Director of Volunteer Services regarding the volunteer's responsibilities to the Medical Center and the patients. Volunteers were issued an identification badge which was to be worn at all times while volunteering.

Review of the Job Shadowing Policy, effective 08/12/10, revealed St. Claire Regional acknowledged it's primary responsibility was to maintain the health, confidentiality and comfort of each patient. Job shadowing participants were to go through orientation prior to participation and would wear a name badge at all times. All participants would be under a mentor's supervision at all times and would not be allowed unrestricted access at the facility. Further review revealed the participant would not be allowed direct patient contact which was defined as physically touching, performing an examination, conducting patient or family counseling, assisting in surgery or performing any other procedure with patients.

Review of the Name Badges Policy, revised 05/09/00, revealed the primary reason for wearing a name badge was to identify the staff member to patients and visitors. All staff members, contract staff and volunteers were to receive and wear Name Badges at all times while performing their duties at SCR.

Interview, on 07/02/12 at 2:55 PM, with the Housekeeper #5 revealed the individual arrived in the ED through the Radiology doors (which were never locked) and told the housekeeper that the college was paying them to volunteer. The housekeeper took the individual to the ED Charge Nurse (CN). Further interview revealed the ED CN gave the "volunteer" scrubs to wear. The housekeeper stated she saw the "volunteer" following the Physician (MD) and Nurses (shadowing them). The housekeeper stated she asked the Physician's Assistant (PA) "Wouldn't it be funny if she's not from the college?". The housekeeper alleged the PA stated it would be like writing a paper on how easy it is to perform patient care without qualifications.

Interview, on 07/03/12 at 8:10 AM, with Registered Nurse (RN) #1, revealed she was the CN in the ED on 06/22/12 and the housekeeper brought the "volunteer" to her. She stated the individual told her, she was a college student and was volunteering for credit. Further interview revealed the CN did not ask to see any identification; however, she should have. The procedure was to call the Coordinator if no name badge was visible. Prior to the incident, the procedure was staff would write their names in a log, if they didn't have their badge. After the incident, the policy changed to staff had to wear their badge and could not work until they received it.

Interview, on 07/02/12 at 11:40 AM, with RN #2 revealed she was the ED CN on 06/23/12 and the individual told her she was shadowing for a couple days and was in a NA course. The "shadowing participant" was wearing scrubs and a lab jacket, knew their way around the ED and acted normal. The individual helped the triage nurse take vital signs by placing the blood pressure cuff on a patient and pushed a button. Further interview revealed the individual wanted to chart in a patient's chart and the CN told her that wasn't allowed. The individual requested the CN give her a report on patients so the individual could start performing NA duties. The CN stated she told the individual she didn't normally do that and the individual called 3 North and left the ED to help 3 North. The CN stated the ED did not use volunteers but the individual told her they were shadowing and the ED did have students who shadow the nurses or MD.


Interview, on 07/03/12 at 9:50 AM, with RN #5 revealed she was the Triage Nurse in the ED on 06/23/12 and the CN brought an individual, from the 4th floor to assist her in the triage room. The individual stated it was her second day in the ED and she wanted to do charting but the RN told her that was the nurses responsibility. Further interview revealed the individual took a patient's blood pressure and oxygen saturation. The RN said she had to show the individual how to put the cuff on five (5) times; however, she didn't think anything of that because different floors have different equipment. She also stated, if she saw someone new, she would ask who they were; however, the individual was brought to her and she was told they were supposed to work.


Interview, on 07/03/12 at 2:00 PM, with RN #3 revealed she was the CN on 3N on 06/23/12, when the individual came to the floor and told her the ED sent her to help on 3N. She didn't ask to see identification nor could she recall if the individual was wearing a name badge. The individual stated she was a nursing student and asked what needed to be done. The individual helped the NA perform direct patient care. Further interview revealed the correct procedure for "floaters" was the Nurse Coordinator should call the CN to let them know help was coming; however, that didn't happen. She did not verify, with the NC or ED, if they sent the individual to help nor did she call security. She also stated she was not responsible for what happened, she could not help it if someone sent a volunteer to help the aides, it was not her job to fix problems. She said she should have verified the person was who they said they were.

Interview, on 07/02/12 at 2:22 PM, with the Director of Critical Care Services revealed the individual told the CN she was a student at the college, was there to shadow