HospitalInspections.org

Based on document review, medical record review and staff interview, the medical staff failed to ensure the physician-employed Registered Nurses (RNs) followed hospital policy when documenting in the medical record in four (4) of nine (9) adult intensive care patient records reviewed (medical records numbered 34, 39, 91 and 93. This has the potential to negatively impact all patient care by resulting in patients not receiving an appropriate physician's assessment. Findings include:

1. Hospital Policy For Registered Nurses Employed By Attending Physicians, last revised 5/10, states in part "1. BACKGROUND INFORMATION ...The privately employed nurse is expected to .... and accountable to practice according to standards outlined in the West Virginia Code for Registered Professional Nurses and all standards of nursing practice as established by CAMC... 2. SCOPE OF PRACTICE ...All requested duties are subject to limitations in the individual Registered Nurse's Scope of Practice authorization. The RN may: A. Assist in rounds by the sponsoring physician and make progress notations in the medical record; B. Transmit or write verbal orders from the physician as per guidelines for CAMC RN; C. Assist the sponsoring physician with diagnostic and other procedures under his/her direct and exclusive supervision... 3. COMPLIANCE ...The RN must comply with the provisions of all applicable state law, Board of Nursing regulation and the Policy of RNs Employed by Attending Physicians at CAMC..."

2. CAMC Professional Nursing policy Privately Employed Scribing for Medical Record Documentation, last revised 9/07, states in part "...POLICY: Privately employed Allied Health Professionals may be authorized to scribe documentation in the medical record for the purpose of correcting illegible handwriting for physicians who have requested authorization from Medical Affairs...PROCEDURE:...2. Scribing will be performed only in the presence of the responsible employing and dictating physician. 3. All scribed entries will be timed, dated and signed immediately by both the scribing nurse and dictating physician..."

3. The West Virginia Board of Examiners for Registered Professional Nurses Delegation Related To A Medical Discharge Summary, adopted 6/10, states in part "...it is within the scope of practice for a registered professional nurse who is not an APRN (advanced practice registered nurse) to extract, collect and compile from the client's medical plans of care, progress notes, and laboratory/diagnostic reports and document or dictate this information to be reviewed and validated by the attending MD/DO. The RN cannot determine a medical diagnosis, medical plan of care, or substitute his/her judgment for that of the MD/DO..."

4. A review of four (4) of nine (9) adult intensive care medical records numbered 34, 39, 91 and 93 revealed evidence the physicians' Nurse Scribe documented in the physician progress notes patient information that was determined to be not according to nursing policy and was outside the limitations of the Nurse Practice Act.

5. Review of the medical record for Patient #34 revealed a physician's progress note dated 6/1/10 at 1605 signed as "scribed for Dr 1/RN 1" and authenticated by the physician on 6/18/10 at 0837.

6. Review of the medical record for Patient #39 revealed a physician's progress note dated 2/12/10 at 1105 and 2/14/10 at 1110 signed as "scribed for Dr 2/RN 2" and authenticated by the physician with no date and/or time, leaving the surveyor unable to determine if it was immediately signed; further review of the medical record revealed a nurses' note dated 2/12/10 at 1050 documenting "RN 2 in to see for Dr 2 and ordered Robitussin and Halls for cough prn..."

7. Review of the medical record for Patient #91 revealed a physician's progress note dated 6/19/10 at 0900 complete with the physician's medical assessment and medical plan of care, signed by RN 3 and authenticated by Dr 3 on 6/19/10 at 1215 and again on 6/20/10 at 0845 by the same RN and authenticated by the same Dr on 6/20/10 at 1140. Further review of the medical record revealed a physician's progress noted dated 6/23/10 at 0845 signed as "scribed for Dr 4/RN 4". As of 6/23/10 at 1443, the progress note had not been authenticated. The medical record was reviewed with the Open Heart Recovery Unit (OHRU) Unit Manager (UM) on 6/23/10 at 1440 and the UM agreed with the findings.

8. Review of the medical record for Patient #93 revealed a physician's progress noted dated 6/17/10 at 0900 complete with the physician's medical plan of care which states in part "...D/W Dr 5 - obtain Chest CT now. Add BiPAP and transfer to ICU..." and signed as "scribed for Dr 5/RN 1" with no documented evidence of authentication by the physician. There is a physician's progress note on the same page with no date or time. There is another physician's progress note dated 6/19/10 at 0920 and signed "scribed for Dr 1/RN 4" with no evidence of physician authentication. There is a physician's progress note documented by the physician on the same page with no date or time. Further review of the medical record revealed a physician's progress note dated 6/22/10 at 0940 and signed "scribed for Dr 1/RN1" with no evidence of physician authentication. There is a physician's progress note documented by the physician on the same page with no date or time. The medical record was reviewed with the Medical Intensive Care Unit (MICU) UM on 6/24/10 at 1105 and the UM agreed with the findings.

9. During a meeting with the Director of Medical Affairs, the Chief Operating Officer and the President of the Medical Staff on 6/31/10 in the afternoon, they agreed with these findings.

Based on document review, medical record review and staff interview, the hospital failed to ensure the physician-employed Registered Nurses (RNs) follow hospital policy when documenting in the medical record in four (4) of nine (9) adult intensive care patient records (Patients #34, 39, 91, 93) reviewed. This has the potential to negatively impact all patient care by resulting in patients not receiving adequate daily physician assessments. The findings include:

1. Charleston Area Medical Center (CAMC) Professional Nursing policy Policy For Registered Nurses Employed By Attending Physicians, last revised 5/10, states in part "1. BACKGROUND INFORMATION ...The privately employed nurse is expected to and accountable to practice according to standards outlined in the West Virginia Code for Registered Professional Nurses and all standards of nursing practice as established by CAMC... 2. SCOPE OF PRACTICE ...All requested duties are subject to limitations in the individual Registered Nurse's Scope of Practice authorization. The RN may: A. Assist in rounds by the sponsoring physician and make progress notations in the medical record; B. Transmit or write verbal orders from physician as per guidelines for CAMC RN; C. Assist the sponsoring physician with diagnostic and other procedures under his/her direct and exclusive supervision... 3. COMPLIANCE ...The RN must comply with the provisions of all applicable state law, Board of Nursing regulation and the Policy of RNs Employed by Attending Physicians at CAMC..."

CAMC Professional Nursing policy Privately Employed Scribing for Medical Record Documentation, last revised 9/07, states in part "...POLICY: Privately employed Allied Health Professionals may be authorized to scribe documentation in the medical record for the purpose of correcting illegible handwriting for physicians who have requested authorization from Medical Affairs...PROCEDURE:...2. Scribing will be performed only in the presence of the responsible employing and dictating physician. 3. All scribed entries will be timed, dated and signed immediately by both the scribing nurse and dictating physician..."

2. West Virginia Board of Examiners for Registered Professional Nurses Delegation Related To A Medical Discharge Summary Position Statement, adopted 6/10, states in part "...it is within the scope of practice for a registered professional nurse who is not an APRN (advanced practice registered nurse) to extract, collect and compile from the client's medical plans of care, progress notes, and laboratory/diagnostic reports and document or dictate this information to be reviewed and validated by the attending MD/DO. The RN cannot determine a medical diagnosis, medical plan of care, or substitute his/her judgment for that of the MD/DO..."

3. Review of the medical record for Patient #34 revealed a physician's progress note dated 6/1/10 at 1605 signed as "scribed for Dr 1/RN 1" and authenticated by the physician on 6/18/10 at 0837.

4. Review of the medical record for Patient #39 revealed a physician's progress note dated 2/12/10 at 1105 and 2/14/10 at 1110 signed as "scribed for Dr 2/RN 2" and authenticated by the physician with no date and/or time, leaving the surveyor unable to determine if it was immediately signed; further review of the medical record revealed a nurses' note dated 2/12/10 at 1050 documenting "RN 2 in to see for Dr 2 and ordered Robitussin and Halls for cough prn..."

5. Review of the medical record for Patient #91 revealed a physician's progress note dated 6/19/10 at 0900 complete with the physician's medical assessment and medical plan of care, signed by RN 3 and authenticated by Dr 3 on 6/19/10 at 1215 and again on 6/20/10 at 0845 by the same RN and authenticated by the same Dr on 6/20/10 at 1140. Further review of the medical record revealed a physician's progress noted dated 6/23/10 at 0845 signed as "scribed for Dr 4/RN 4". As of 6/23/10 at 1443, the progress note had not been authenticated. The medical record was reviewed with the Open Heart Recovery Unit (OHRU) Unit Manager (UM) on 6/23/10 at 1440 and the UM agreed with the findings.

6. Review of the medical record for Patient #93 revealed a physician's progress noted dated 6/17/10 at 0900 complete with the physician's medical plan of care which states in part "...D/W Dr 5 - obtain Chest CT now. Add BiPAP and transfer to ICU..." and signed as "scribed for Dr 5/RN 1" with no documented evidence of authentication by the physician. There is a physician's progress note on the same page with no date or time. There is another physician's progress note dated 6/19/10 at 0920 and signed "scribed for Dr 1/RN 4" with no evidence of physician authentication. There is a physician's progress note documented by the physician on the same page with no date or time. Further review of the medical record revealed a physician's progress note dated 6/22/10 at 0940 and signed "scribed for Dr 1/RN1" with no evidence of physician authentication. There is a physician's progress note documented by the physician on the same page with no date or time. The medical record was reviewed with the Medical Intensive Care Unit (MICU) UM on 6/24/10 at 1105 and the UM agreed with the findings.

7. During an interview on 6/24/10 at 1115 with the Director of Medical Affairs and the Director of Nursing (DON), the above information was reviewed and both agreed with the findings.

Based on survey observations, it was determined the hospital failed to maintain adequate facilities for its services compliant with Federal and State laws, regulations and guidelines. Findings include:

1. At 1:35 PM on June 21, 2010, acoustic type ceiling tiles that can not be cleaned were found in the sub-sterile corridor of the surgery suite. (Reference 8.2.3.4 AIA Guidelines for Design and Construction of Health Care Facilities.) (Women and Children's Division)

2. At 3:50 PM on June 23, 2010, the soiled utility room in the women's center was found being used for clean storage creating a potential for cross contamination between soiled and clean supplies. (Women and Children's Division)

3. At 10:10 am on June 22, 2010, the kitchen floor was found heavily soiled with debris and dirt behind the ice machines and coolers located in the vicinity of the steam line. (Women and Children's Division)

4. At Approximately 3:55 PM on June 28, 2010, the endoscopy decontamination room was found to not have negative air flow. (Reference Table 2-1-2 AIA Guidelines for Design and Construction of Health Care Facilities.) (Memorial Division)

5. At approximately 10:10 AM on June 24, 2010, developer fumes from the surgery x-ray dark room were present in the surgery sub-sterile corridor. The room was found to not have sufficient exhaust air to remove developer fumes. (Reference Table 2-1-2 AIA Guidelines for Design and Construction of Health Care Facilities.) (Memorial Division)

6. At approximately 2:00 PM on June 24, 2010, surgery room humidity levels were observed on the computer monitoring system in the engineering department and found to exceed the maximum rate of 60%. Humidity levels ranged between 61 and 73%. High and low level alarms were set to alert staff when humidity levels dropped below 20% or got higher than 80%. (Reference Table 2-1-2 AIA Guidelines for Design and Construction of Health Care Facilities.) (Memorial Division)

7. At approximately 1:25 PM on June, 28, 2010, soiled utility room doors were found unlocked in the Cardiac Cath Lab. prep unit. (Memorial Division)

8. At approximately 4:35 PM on June 28, 2010, the hand washing sink serving emergency room exam cubicles 11-15 was found to be located behind the cubicle curtains in cubicle # 11, making it not readily accessible to staff. Thus, creating a potential for cross contamination. (Memorial Division)

9. At approximately 5:00 PM on June 28, 2010, a laboratory area was observed set up unprotected from unauthorized access in the emergency room corridor equipment alcove. The area contained syringes, needles, two Bio-hazard refrigerators and a urine specimen refrigerator all found unlocked. (Memorial Division)

10. Janitors carts, soiled linen and trash containers, described by staff as trucks, having an estimated capacity of 100 or more gallons are stored in the sub sterile scrub sink area outside each operating room. Staff stated that the mobile containers are not moved until they are filled and the mop buckets remain there between surgery procedures. Storage of this type near the scrub sinks creates a potential for infection and cross contamination. (Memorial Division)