HospitalInspections.org

Based on record review and interviews, the hospital failed to ensure that health care services were provided in accordance with applicable state laws by failing to ensure that a Registered Nurse (RN) assessed the patient care situation and acuity of the patient before delegating the care of the patient to a Licensed Practical Nurse (LPN), and/or a sitter, for 8 patients (#1, #2, #4, #5, #7, #9, #10, #12) of 14 (#1- #14) sampled closed records reviewed and 6 patients (#15, #16, #17, #18, #20, #21) of 7 (#15-21) sampled active records reviewed as evidenced by: (1) Licensed Practical Nurses providing triage and initial nursing assessments in the ED (Emergency Department); (2) Licensed Practical Nurses providing care to patients on the medical/surgical unit without patients first being assessed by a Registered Nurse; (3) Nurses and sitters providing care for psychiatric patients in the ED without crisis intervention training for the care of psychiatric patients in the ED.
Review of the Louisiana State Board of Nursing's "Administrative Rules Defining RN Practice LAC46:XLVII" revealed, in part, "3703. Definition of Terms Applying to Nursing Practice ... Delegating Nursing Interventions - ... The registered nurse retains the accountability for the total nursing care of the individual. ... The registered nurse shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems. The assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required. a. Any situation where tasks are delegated should meet the following criteria: i. the person has been adequately trained for the task; ii. the person has demonstrated that the task has been learned; iii. the person can perform the task safely in the given nursing situation; iv. the patient's status is safe for the person to carry out the task; v. appropriate supervision is available during the task implementation; vi. the task is in an established policy of the nursing practice setting and the policy is written, recorded and available to all. b. The registered nurse may delegate to licensed practical nurses the major part of the nursing care needed by individuals in stable nursing situations, i.e. (that is), when the following three conditions prevail at the same time in a given situation: i. nursing care ordered and directed by R.N./M.D. (medical doctor) requires abilities based on a relatively fixed and limited body of scientific fact and can be performed by following a defined nursing procedure with minimal alteration, and responses of the individual to the nursing care are predictable; and ii. change in the patient's clinical conditions is predictable; and iii. medical and nursing orders are not subject to continuous change or complex modification...".
Findings:
(1) Licensed Practical Nurses providing triage and initial nursing assessments in the ED (Emergency Department)
Patient #1
Review of Patient #1's triage assessment and initial nursing assessment revealed the triage and nursing assessment was performed on 09/11/13 at 8:47 p.m. by S5LPN. Further review revealed Patient #1 was discharged from the ED, and an assessment was not performed by a RN (Registered Nurse).

Patient #2
Review of Patient #2's triage assessment and initial nursing assessment revealed the triage and nursing assessment was performed on 09/26/13 at 7:42 p.m. by S11LPN. Further review revealed Patient #2 was discharged from the ED, and an assessment was not performed by a RN.

Patient #4
Review of Patient #4's triage assessment and initial nursing assessment revealed the triage and nursing assessment was performed on 12/06/13 at 11:00 p.m. by S6LPN. Further review revealed Patient #4 was discharged from the ED, and an assessment was not performed by a RN.

Patient #5
Review of Patient #5's triage assessment and initial nursing assessment revealed the triage and nursing assessment was performed on 12/17/13 at 12:15 a.m. by S6LPN. Further review revealed Patient #5 was given a dose of medication by an RN at 1:30 a.m., and there was no documentation of an assessment by the RN. Patient #5 left the ED at 1:45 a.m. AMA (Against Medical Advice).

Patient #9
Review of Patient #9's triage assessment and initial nursing assessment revealed the triage and nursing assessment was performed on 04/11/14 at 11:35 p.m. by S6LPN. Further review revealed Patient #9 was discharged from the ED, and an assessment was not performed by a RN.

Patient #10
Review of Patient #10's triage assessment and initial nursing assessment revealed the triage and nursing assessment was performed on 10/18/13 at 6:55 a.m. by S7LPN. Further review revealed Patient #10 was discharged from the ED, and an assessment was not performed by a RN.

Patient #12
Review of Patient #12's triage assessment and initial nursing assessment revealed the triage and nursing assessment was performed on 03/11/14 at 8:05 p.m. by S7LPN. Further review revealed Patient #12 left the hospital AMA on 03/11/14 at 9:35 p.m., and an assessment was not performed by a RN.

Patient #15
Review of Patient #15's triage assessment and initial nursing assessment revealed the triage and nursing assessment was performed on 04/16/14 at 9:20 a.m. by S9LPN. Further review revealed there was no documentation in the medical record that Patient #15 was assessed by a RN, and Patient #15 was discharged by S8RN on 04/16/14 at 10:20 a.m.

Patient #16
Review of Patient #16's triage assessment and initial nursing assessment revealed the triage and nursing assessment was performed on 04/16/14 at 9:05 a.m. by S9LPN. Further review revealed Patient #16 was discharged from the ED, and an assessment was not performed by a RN.

Patient #17
Review of Patient #17's triage assessment and initial nursing assessment revealed the triage and nursing assessment was performed on 04/16/14 at 11:56 a.m. by S10LPN. Further review revealed Patient #17 was discharged from the ED, and an assessment was not performed by a RN.

Patient #18
Review of Patient #18's triage assessment and initial nursing assessment revealed the triage and nursing assessment was performed on 04/16/14 at 11:00 a.m. by S10LPN. Further review revealed Patient #18 was discharged from the ED, and an assessment was not performed by a RN.
In an interview on 04/17/14 at 9:50 a.m., S4ED Manager indicated the triage nurse should "preferably be a RN, but when I can't get a RN triage nurse, it may be a seasoned LPN." She further indicated that when a triage nurse isn't present, the nurse does the bedside triage, and this could be done by a RN or LPN. She confirmed that a nurse didn't know a patient's condition until the patient was triaged. When asked if she was aware of the LSBN's guidelines regarding the RN's delegation to the LPN, she answered, "I've read it but it's been awhile."

In an interview on 04/17/14 at 10:00 a.m., S4ED Manager verified the findings that the above referenced patients (#1, #2, #4, #5, #9, #10, #12, #15, #16, #17, #18) were triaged and/or had nursing assessments performed by a Licensed Practical Nurse (LPN), and the patients did not have a nursing assessment performed by a Registered Nurse in the Emergency Department prior to the care of the patient being delegated to a LPN.

(2) Licensed Practical Nurses providing care to patients on the medical/surgical unit without patients first being assessed by a Registered Nurse.
Patient #20
Patient #20 is a 70-year-old female admitted to the hospital on 04/07/14 with the diagnoses of dehydration and hypernatremia.
Review of the medical record for Patient #20 revealed following dates and shifts for Patient #20 where nursing care was provided by an LPN without a RN assessment:
04/07/14: 7:00 p.m. to 7:00 a.m. shift by a LPN; LPN reported off to another LPN for the 7:00 a.m. to 7:00 p.m. shift.
04/08/14: 7:00 a.m. to 7:00 p.m. shift by a LPN; LPN reported off to another LPN for the 7:00 p.m. to 7:00 a.m. shift.
04/10/14: 7:00 p.m. to 7:00 a.m. shift by a LPN; LPN reported off to another LPN for the 7:00 a.m. to 7:00 p.m. shift (for 04/11/14).
04/11/14: 7:00 p.m. to 7:00 a.m. shift by a LPN; the LPN reported off to another LPN for the 7:00 p.m. to 7:00 a.m. shift (for 04/12/14).
04/12/14: 7:00 a.m. to 7 p.m. shift by a LPN; the LPN reported off to another LPN for the 7:00 p.m. to 7:00 a.m. shift (for 04/13/14).
In an interview on 04/16/14 at 4:20 p.m., S19Med/Surg Manager verified and confirmed the nursing care for the above referenced dates and shifts for Patient #20 were provided by LPN's without a RN assessment completed prior to delegating the nursing care for Patient #20 to a LPN.

Patient #21

Review of Patient #21's medical record revealed he was a 79 year old male admitted on 04/15/14 with diagnoses of Exacerbation of COPD (Chronic Obstructive Pulmonary Disease), Cardiac Lymphoma, Non-Insulin Dependent Diabetes Mellitus, HCVD (Hypertensive Cardiovascular Disease), and Hyperlipidemia.

Review of Patient #21's "Patient Progress Notes" revealed his care was delegated to S13LPN (licensed practical nurse) by S15RN (registered nurse) on 04/15/14 at 7:30 p.m. Further review revealed S13LPN documented an assessment of Patient #21 on 04/15/14 at 7:30 p.m. and assessments as "no change in previous assessment" on 04/15/14 at 9:00 p.m., 11:00 p.m., and on 04/16/14 at 1:00 a.m., 3:00 a.m., 5:00 a.m., and 6:30 a.m. S13LPN documented that S14LPN received a call from the lab on 04/16/14 at 7:21 a.m. with a report of a critical Prothrombin Time of 57.5 (high is 12.0) and critical International Normalized Ratio (INR) of 4.9 (high is 2.0) for Patient #21, and S13LPN notified Patient #21's physician at 7:25 a.m. with no new orders received. Further review revealed no documented evidence that S13LPN reported the critical lab value to a RN, and there was no documented evidence that Patient #21 was assessed by a RN for signs and symptoms of bruising and bleeding. There was no documented evidence that a RN educated Patient #21 on precautions to take to avoid increased bleeding or bruising while his Prothrombin Time and INR were critically high.

Review of Patient #21's "Patient Progress Notes" revealed his care was transferred by S13LPN to S12LPN on 04/16/14 at 7:38 a.m. with no documented evidence of an assessment by a RN to determine if Patient #21's condition was stable and met the criteria for his care to be delegated to a LPN according to the LSBN's (Louisiana State Board of Nursing) Nurse Practice Act.

In an interview on 04/16/14 at 3:55 p.m., S19Med/Surg (Medical/Surgical) Manager confirmed there was no documented evidence that a RN was notified of Patient #21's critical Prothrombin and INR lab values.

In an interview on 04/16/14 at 3:57 p.m., S19Med/Surg Manager confirmed that a RN did not assess Patient #21 before his care was delegated to S12LPN on 04/16/14 at 7:38 a.m.

In an interview on 04/17/14 at 8:55 a.m., S2CNO (Chief Nursing Officer) indicated a RN should have documented an assessment of Patient #21 for bleeding or bruising that could have resulted from the elevated Prothrombin and INR lab values. She further indicated the RN should have educated Patient #21 on precautions necessary to decrease his risk of bleeding.



(3) Nurses and sitters providing care for 1 psychiatric patient (#7) of 14 (#1-#14) sampled closed records reviewed in the ED without proper orientation and training for the care of psychiatric patients in the ED.

Review of the hospital policy titled "Care of the Medically Stable Psychiatric Patient", presented as a current policy by S4ED Manager, revealed all potential suicidal patients should have every effort made to obtain an observation sitter at the bedside. Further review revealed an assessment of psychiatric patients included a history of present illness and past psychiatric and/or substance abuse history, including precipitating events and stressors, patient specific statements, behavioral changes, thought disturbances, hallucinations, delusions, and/or thoughts of hurting oneself or others. Further review revealed that an assessment is performed by the ED physician upon arrival, every 12 hours, and more often if deemed necessary. Patient's vitals signs were to be obtained and recorded every 4 hours or sooner as needed. Further review of the policy revealed no documented evidence of how often the RN was to assess the medically stable psychiatric patient in the ED.

Review of the "Observation Sitter Guidelines", presented by S4ED Manager as the current guidelines for sitters who observe psychiatric patients in the ED, revealed that sitters sit in the patient's room with an unobstructed view of the patient and keeps the patient within visual contact at all times.

Patient #7
Review of Patient #7's ED record revealed he was a 51 year old male who presented to the ED on 02/05/14 at 12:25 a.m. with a chief complaint of not sleeping for days. Review of Patient #7's "Emergency Physician Record" documented by S17ED Physician on 02/05/14 at 12:30 a.m. revealed Patient #7 took 5 Adderall 30 mg (milligrams) pills that he bought off the street and believes that the FBI (Federal Bureau of Investigation) is after him. Further review revealed that S17ED Physician's clinical impression was Acute Exacerbation of Psychosis/Schizophrenia and Intentional Drug Overdose. S17ED Physician executed a PEC (Physician's Emergency Certificate) on 02/05/14 at 2:13 a.m. due to Patient #7 being dangerous to self and unable to seek voluntary admission.

Review of Patient #7's "Emergency Physician Record" revealed he was re-assessed by a physician on 02/05/14 at 9:30 a.m. and 11:00 p.m. and on 02/06/14 at 10:15 p.m. Further review of his ED record revealed Patient #7 was transferred to a behavioral health hospital on 02/07/14 at 10:00 a.m. There was no documented evidence that Patient #7 was assessed every 12 hours by a physician as required by hospital policy.

Review of Patient #7's medical record revealed he was assessed by a RN on 02/05/14 at 12:25 a.m., and S18RN reported to S16RN on 02/05/14 at 5:00 p.m. There was no documented evidence of an assessment of Patient #7 by S16RN. Review of the "ED Nursing Assessment/Nursing Notes" revealed no RN assessment between the time S18RN documented that she reported to him and the time of an assessment of Patient #7 by S9LPN on 02/05/14 at 6:15 a.m. There was no documented evidence that Patient #7 was assessed by a RN to determine that he met criteria for his care to be delegated to a LPN according to LSBN's practice act. Further review revealed there was no documented evidence of a RN assessment of Patient #7 prior to his care being delegated to S6LPN on 02/05/14 at 6:00 p.m. Further review revealed S6LPN provided care for Patient #7 from 6:00 p.m. on 02/05/14 until 5:30 a.m. on 02/06/14. There was no documented evidence that Patient #7 was assessed by a RN for 36 hours while he remained in the ED.

Review of Patient #7's entire ED record from his arrival on 02/05/14 at 12:25 a.m. until his transfer on 02/07/14 at 10:00 a.m. revealed his vital signs were assessed on 02/05/14 at 12:25 a.m., on 02/05/14 at 6:00 p.m., and at 10:00 a.m. on 02/07/14. There was no documented evidence that Patient #7's vital signs were assessed and documented every 4 hours as required by ED policy.

Review of Patient #7's "ED Nursing Assessment/Nursing Notes" revealed S6LPN documented that she notified the nurse supervisor on 02/05/14 at 6:45 p.m. that Patient #7 had not been placed in a behavioral unit, and there was no sitter at the bedside (18 hours and 20 minutes after his arrival).

In an interview on 04/17/14 at 9:50 a.m., S4ED Manager confirmed that Patient #7's vital signs were not assessed every 4 hours as required by hospital policy, and the ED physician did not document an assessment every 12 hours as required by hospital policy. She indicated that the nurse was supposed to re-assess a patient every 12 hours while the patient was in the ED. She further indicated there was one shift where S16RN did not document assessments for his entire shift. She confirmed there was no RN assessment between the assessments and care performed by S9LPN and S6LPN. S4ED Manager indicated that Patient #7 should have had a sitter assigned as soon as he was PEC'd.

Review of the personnel files of S20ED Clerk, S13LPN, S6LPN, S18RN, S21RN, and S22RN, all employees who provide nursing care or were assigned as a sitter for psychiatric patients in the ED, revealed no documented evidence of orientation, training, and an evaluation of competency for caring for the psychiatric patient in the ED. Further review revealed no documented evidence of training in non-violent crisis intervention techniques.
In an interview on 04/17/14 at 9:50 a.m., S4ED Manager indicated the hospital did not have a policy that addressed how the safety of the psychiatric patient in the ED would be maintained. She further indicated there were sitter guidelines that the staff assigned as a sitter has to read and sign. She indicated that sometimes the police officer who is contracted as security for the hospital may be the assigned sitter. S4ED Manager indicated the police officer is not trained by the hospital on non-violent crisis intervention and care of the psychiatric patient in the ED.
In an interview on 04/17/14 at 1:55 p.m., S2Chief Nursing Officer (CNO) indicated she didn't have the police officer's personnel file to present, and it didn't have evidence of training by the hospital for providing care of the psychiatric patient in the ED when he/she was assigned as a sitter. She confirmed that the personnel files of S20ED Clerk, S13LPN, S6LPN, S18RN, S21RN, and S22RN did not have evidence of orientation, training, and an evaluation of competency for caring for the psychiatric patient in the ED.


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