HospitalInspections.org

Based on document review and staff interview, it was determined the hospital failed to provide written notice to one (1) of one (1) complainants whom filed a grievance with the hospital (patient #1). This has the potential to adversely affect the resolution of grievances filed with the hospital.
Findings include:

1. A review of the hospital's grievance file revealed there had been a grievance lodged on behalf of patient #1. Although there was discussion with both the patient's son and daughter relative to the grievance, there was no indication a written notice had been sent to the complainant.

2. During a joint interview with one of the hospital's Lawyers and with the hospital's Director of Quality Assurance in the morning of 3/10/10, both agreed the complainant had not received written notification relative to the grievance filed on behalf of patient #1.

Based on document review and staff interview, it was determined the medical staff failed to conduct an appraisal for one (1) of twenty-nine (29) Medical Associates within an acceptable time period (RN/Medical Assistant #1). This has the potential to allow a Medical Associate to be functioning without the Medical Staff having determined their suitability. Findings include:

1. A review of the Medical Staff Bylaws, Rules & Regulations (Adopted 1/2009) revealed (in part):
"Section 2. Selection Procedure:
(a) To the extent the Board determines to permit such Medical Assistants to act in the hospital, the Credentials Committee shall recommend to the Board the scope of each such individual's activities within the hospital.
(b) No such individual shall provide services in the hospital as a Medical Assistant unless and until the Credentials Committee has received, on a form approved by the Board, sufficient information about the qualifications of that individual to permit the Credentials Committee to recommend the scope of activities the individual will be permitted to undertake in the hospital. the form shall be prepared by the individual's supervisor and signed by both the supervisor and the individual.
(c) The Credentials Committee, on the recommendation of the chairman of the applicable department, shall recommend to the Board a written delineation of the scope of activities each Medical Assistant is permitted to undertake in the hospital. This delineation shall be final with no right of hearing or appeal, provided, however, that the physician seeking to supervise the Medical Assistant in the hospital shall have the opportunity to appear before the Credentials Committee and discuss the proposed delineation before any final action is taken on it by the Board. The Medical Assistant may act in the hospital pursuant to the approved delineation only so long as he remains an employee of or is supervised by a physician currently appointed to the medical staff."

2. A review of the credentials file for RN/Medical Assistant #1 revealed that although she is currently working at the hospital, her reappointment (approved by the Credentials Committee, the Medical Executive Committee and the Board of Trustees) extended only through 12/31/2007.

3. During interview with the Medical Staff Secretary in the afternoon of 3/10/10, she agreed the reappointment of RN/Medical Assistant #1 had extended only through 12/31/07. The Medical Staff Secretary said she had called the nurse yesterday (3/10/10) and told her she could not resume working until she was recredentialed.

Based on document review and staff interview, it was determined the Medical Staff failed to enforce its bylaws relative to what Medical Assistants are allowed to engage in as granted by the Board. This practice affected two (2) of two (2) patients (patients #1 and #8). This has the potential for nurses to be operating out of their scope of practice.
Findings include:

1. A review of the Medical Staff Bylaws, Rules & Regulations (Adopted 1/09) revealed (in part):
"Section 3. Condition of Practice:
(a) Medical Assistants shall practice in the hospital at the discretion of the Board and may be terminated at will by the Board. Neither the Medical assistant nor his supervisor shall be entitled to any hearing or appeal upon such termination.
(b) Medical assistants shall not be entitled to the rights, privileges, and responsibilities of appointment to the medical staff and may engage in acts within the scope of practice specifically granted by the Board.
(c) Any activities permitted by the Board to be done in the hospital by Medical Assistants shall be done only under direct and immediate supervision. "Direct and immediate supervision" may require the actual physical presence of the supervisor if so required by the Credentials Committee or its approved protocols. Should any hospital employee who is licensed or certified by the state have any question regarding the clinical competence or authority of the Medical Assistant either to act or to issue instructions outside the physical presence of the supervisor in a particular instance, such hospital employee has the right to require that the Medical Assistant's supervisor validate, either at the time or later, the instructions of the Medical Assistant. Any act or instruction of the Medical Assistant shall be delayed until such time as the hospital employee can be certain that the act is clearly within the scope of the Medical Assistant's activities as permitted by the Board. At all times the supervising physician will remain responsible for all acts of any of his Medical Assistants within the hospital.
(d) The number of Medical Assistants acting under the supervision of one physician, as well as the acts they may undertake, shall be consistent with applicable state statutes and regulations, the rules and regulations of the medical staff and the policies of the Board."

2. A review of the medical record of patient #1 revealed the cardiology consult had been written by RN (Registered Nurse)/Medical Assistant #1.

3. A review of the medical record of patient #8 revealed the gastroenterology consult had been written and dictated by RN/Medical Assistant #2. This nurse also had written physician progress notes.

4. During an interview with the RN/Medical Assistant #2 at 1205 on 3/10/10 regarding job function with the Gastroenterologist, the RN stated her role is to gather patient information, dictate typically after the patient is seen by the physician, write daily progress notes and then the physician will round after her and sign them. When asked for clarification of when she writes the physician's progress notes and consultation reports, she stated she writes them before the physician actually sees the patient but she calls him on the phone and talks to him about the patient before she writes anything. The surveyor then asked the RN/Medical Assistant if she had obtained approval from the State RN Board or special certifications to perform these functions and the RN/Medical Assistant stated "No, only on the job training from the doctor."

5. One of the hospital's Attorneys was interviewed in the afternoon of 3/10/10 relative to a RN/Medical Assistant writing and dictating consultation notes and she replied "She should not be doing that. She's a RN."

Based on document review, medical record review and staff interview, the hospital failed to ensure the nursing staff follows hospital policy when providing for skin care in one (1) of five (5) closed medical records reviewed (patient #1). This has the potential to negatively impact all patient care by not maintaining healthy skin and/or preventing breakdown of compromised skin of patients. Findings include:

1. Thomas Memorial Hospital Policy and Procedure Skin Care/Therapeutic Beds PC 43.1, last revised 2/2010, states in part "...III. SCOPE & RESPONSIBILITY: The licensed nurse is responsible for performing and documenting a Skin Risk Assessment/Reassessment, communicating assessment/reassessment findings to the physician and implementing appropriate skin care management...IV. Assessment: 1. Skin Risk Assessment/Reassessment is performed on all inpatients upon admission per defined unit timeframes, utilizing a Braden Pressure Ulcer Risk Assessment...2. Based on the findings during the Braden screening, a patient is determined to be:...At moderate risk for compromised skin integrity (Total score of 13-15)...B. Intervention According to Braden Degree of Risk: 2. Moderate Risk (13-15)* If other major risk factors are present, advance to high risk...If bed bound, reposition every two (2) hours; if chair bound, reposition every hour; increase mobility and activity as tolerated; offer fluids as tolerated when turning patient; elevate heels off bed surface and avoid skin-to-skin contact; keep the head of the bed at a 30-degree angle or lower unless otherwise indicated by physician or nurse; keep individual off trochanter (hip) or wound with positioning; manage moisture, nutrition, friction and shear; use pressure reduction device and/or therapeutic bed per guidelines; consult wound care nurse...C. Interventions and Reassessment: Reassessment and documentation of skin integrity occurs each shift utilizing the Nursing Care Record, to monitor the progress and evaluate the outcomes of therapies instituted or utilized in the treatment of impaired skin integrity...1. Prevention: a. Preventive measures based on recognition of source of skin irritation/compromise: Excoriation: Initiate appropriate perineal care and evaluate for internal/external catheter or fecal collection device...b. Place patients who are at moderate to high risk for skin breakdown on pressure relieving device. Evaluate need for therapeutic bed...c. If patient is incontinent, use a peri-wash to clean and apply protective barrier ointment after each incontinent episode...h. Maintain dry environment...2. Intervention: If the patient develops compromised skin integrity while in the facility an occurrence report is to be completed..."

2. Review of the medical record for Patient #1 revealed the Admission Assessment History was completed on 1/20/10 at 2120 and the Initial Assessment was completed on 1/20/10 at 2045. The documentation of the patient's skin integrity on admission revealed the patient's left arm above and below the elbow had brown discolorations, the skin was intact; a scab had fallen off the right elbow, the skin was intact, area dry; and an old bruise to the left temporal area; otherwise no alterations in skin integrity. The patient scored 13 on the initial Braden Pressure Ulcer Risk Assessment. No other alterations in skin integrity were documented in the medical record until 0330 on 1/24/10 when the nurse documented the perineal area to be excoriated. The first documented evidence of the facility obtaining a therapeutic bed for the patient, per policy, was 1/25/10. There was documented evidence of multiple instances of the patient being incontinent of urine and bowel with sporadic and inconsistent documented evidence of appropriate skin care and application of protective barrier ointment, per policy. There is also no documented evidence of physician orders to treat the affected area until 2/1/10.

3. During review of the patient's medical record with the Information Systems Registered Nurse Liaison (ISRN) in the afternoon of 3/8/10, the ISRN agreed with the above findings.

Based on document review, medical record review and staff interview, the hospital failed to ensure the medical staff AND nursing staff follows appropriate guidelines when obtaining informed consent for surgical procedures in one (1) of one (1) open surgical medical record (Patient #8) reviewed. This has the potential to negatively impact all patient care by patients and/or their representatives not being given necessary and adequate information to enable making an informed decision regarding treatment. Findings include:

1. Thomas Memorial Hospital Essential Steps procedure Informed Consent, last revised 9/2009, states in part "...1. Ensure the attending physician has explained the nature of the medical condition to the patient and has informed the patient or the person legally permitted to consent for the patient, of the name and nature of the proposed operation(s), special procedure(s) or treatment(s) and the risks and hoped-for benefits. The alternative methods of treatment and those related risks and consequences of remaining untreated should also be discussed by the attending physician...2. Complete the "Authorization for Medical or Surgical Treatment" form...3. Sign as a witness to the signing of the applicable consent form..."

2. At 1130 on 3/10/10 during review of the medical record for Patient #8, the "Disclosure and Informed Consent" form for a Laparoscopic, possible Open-Cholecystectomy procedure was found with the patient's signature timed for 0810, with the LPN's signature with no date or time but with no Physician signature. There was no documented evidence of any other Informed Consent for this procedure or notation in the physician progress notes of obtaining informed consent.

3. During review of the patient's medical record with the Information Systems Registered Nurse Liaison (ISRN) in the morning of 3/10/10, the ISRN agreed with the above findings.