HospitalInspections.org

Based on medical record reviews, document reviews and staff interviews, it was determined the facility failed to follow policies and procedures for monitoring probationary employees for one (1) Employee (Emp #2) of one (1) Employees being monitored on probation. This failure has the potential to negatively impact all patients receiving care at the facility.

Cross-Reference: §482.23(b)(6) All nurses must adhere to the policies and procedures of the hospital.

Based on medical record reviews, document reviews and staff interviews, it was determined the facility failed to follow policies and procedures for probationary employees for one (1) Employee (Emp) of one (1) employee training a probationary employee. This failure has the potential to negatively impact all Patients receiving care at the facility.

Findings

A review of the policy, titled "Probationary Employees," approved 04/16/09. The policy states, in pertinent part, "... Procedure: It is the policy of Appalachian Regional Healthcare, Inc., (ARH) that all new employees and all present employees transferred or promoted to a new job should be carefully monitored and evaluated for an initial introductory period. I. Probationary Period A. The probationary period for ARH employees (excepting employees governed by collective bargaining agreements) shall last for a period of ninety (90) calendar days. This can be extended up to an additional ninety (90) days. II. Supervisors Responsibilities. A. Supervisors should carefully observe the performance of each employee in a new job position. Where appropriate, weaknesses and performance, behavior, or development should be brought to the employee's attention for correction. B. Supervisor should prepare a minimum of two (2) written evaluations of the employees, job performance, once during the probationary period and the second prior to the end of the probationary period. See probationary employee evaluation. The evaluation should include a recommendation as to whether the employee should continue in the position. Copies of the evaluation should be forwarded to the Human Resources Department for review to ensure consistency with this policy. After reviewing the Human Resources Department will forward to the Community Chief Executive Officer or Vice President for final approval ..."

Education and personnel files were reviewed for emp #1, emp #2, emp #3, emp #4 and emp #8. All staff have appropriate active licensure and have current training in Medication Administration, CPR, and Incident Reporting. However, Emp #2 did not have any competency and performance evaluations after emp #2 became a Registered Nurse on 02/2024.

An interview was conducted with Emp #13 on 05/01/24 at 1:20 p.m. regarding the transfer and promoted employees that the supervisors should follow the policy, "Probationary Employees."

An interview was conducted with Emp #10 on 05/01/24 at 9:45 a.m. revealed that when a nurse is administering a medication that they have never administered before "my expectation would be, from a pharmacy standpoint, that the nurse should consult with the preceptor."

On 05/01/24 at 2:00 p.m., Emp #4 concurred no additional competencies or evaluations were completed for Emp #2 after Emp #2 obtained a Registered Nursing license and reassigned the role of Registered Nurse from Licensed Practical Nurse.

Graduate Nurse Medication Administration Procedure:

A review of the medical record for Patient #1, revealed in part, the patient was admitted on 04/18/24 at 8:51 p.m. for diabetic problems with necrotic toes requiring amputation. On 04/24/24 the patient became agitated and combative with nursing staff. Ativan 2 milligram (mg) IV (Intravenous) given for agitation at 12:43 a.m. The patient was still agitated, and Geodon 20 mg IV was administered on 04/24/24 at 3:07 a.m. by Emp #1. The patient went into cardiac arrest at 3:20 a.m. and cardiopulmonary resuscitation was started. The patient was intubated and transferred via bed to the intensive care unit. The Patient remained intubated in ICU until the Patient passed away 04/30/24.

A telephone interview was conducted with Emp #1 on 04/30/24 at 12:33 p.m. When asked how Emp #1 was involved in the incident, Emp #1 states, in part, "I was directly involved in the incident. It was unfortunately my mistake. "I was the one who administered the medication that caused the patient to go into cardiac arrest. [Patient #1] was trying to hit the nurses. I came out of the Patient's room and discussed the Patient's care with my preceptor [Emp #2]. The decision was made to administer Geodon. I told my preceptor that I had never given Geodon before and asked if there was anything I needed to know? My preceptor told me it was just like the previous medication given [Ativan].When asked why Emp #1 administered Geodon as IV, Emp #1 responded, "I did not know the medication was supposed to be IM [Intramuscular injection] since my preceptor told me it was like Ativan and Ativan can be given IV. I administered the drug and pressed the given button after I administered the drug because it was not scannable and then there was a screen asking for the site given. That's when I realized that I made a mistake." When asked if they were on orientation/probabtion they stated in part? Yes, [states Emp #2's name] is my preceptor. When asked if the preceptor was in the room when the medication was administered? Emp #2 stated, "No".

An interview was conducted on 05/01/24 at 10:50 a.m. with emp #4 it revealed in part, that when a graduate nurse was going to administer a medication that they have never administered before, the expectation is "If a graduate nurse had never given the medication, the preceptor should go in with the graduate nurse."

A phone interview was conducted with emp #11 on 05/01/24 at 10:51 a.m. When asked what Emp #11's expectation is if the orientee had never administered Geodon, emp #11 stated, in part, "The expectation is the preceptor is with the orientee ..."

A telephone interview was conducted with emp #12 on 05/01/24 at 1:30 p.m. Emp #12 expressed, "If it is a new nurse and the nurse had never administered the medication before, the preceptor should be at the bedside."