HospitalInspections.org

Based on review of policies/procedures, personnel files and staff interviews, it was determined the administrator failed to require a process for verifying the status of out of state nursing licensure for 1 of 1 registered nurses (RN) employed with an out of state license(employee #22).

Findings include:

Review of policy "Certifications" revealed: "...Department managers are to maintain documentation of currently valid credentials applicable to their departments...Some employees may be hired with the understanding that they require a particular license, registration or certification within a specific time frame...."

A review of the personnel file for employee #22 revealed the following:

1. The policy "Job Description/Evaluation Registered Nurse" revealed: "...Must hold a current state license and must maintain license renewal in accordance with the standards of the State Board of Nursing...."

2. The requirement "National Council of State Boards of Nursing (NCSBN) Nurse Licensure Compact (NLC)" revealed: "...a nurse changing primary state of residence from one party NLC state to another, may continue to practice under the former state license if (including the NLC privileges) processing of the nurse's new licensure application in the new state of residency does not exceed 30 days...."

3. The National Council of Board of Nursing Licensure QuickConfirm Report for employee #22, revealed, "...Compact Status: Single State...." This report was dated 2/15/12.

4. Employee #22 was hired 7/8/07, with an Iowa state registered nurse license expiration date of 2/15/09, and a renewed Iowa state registered nurse license expiration date of 2/15/12.

Interview with employee #'s 4 and 5 confirmed on 5/16/13 at 1300 hours, that they did not verify the status of employee #22's Iowa nursing license, which indicated employee #22 only had single state privileges after discipline was taken in Iowa against the license 01/09/06. Employees #'s 4 and 5 confirmed employee #22 did not have a current Arizona State nursing license since date of hire on 07/08/07. Employee #4 explained that she was not aware of the National Council of State Boards of Nursing (NCSBN) Nurse Licensure Compact (NLC) requirements and this had been an education. She confirmed the hospital did not have a policy or procedure in place to verify out of state nursing license status, nor did they develop a procedure after discovering employee #22 practiced on an out of state single state nursing license.

Based on review of Patient #4's medical record, policies/procedures, and staff interviews, it was determined the nurse executive failed to require a nurse:

1. documented or reassessed a blood pressure of 76/57 at 2000 hours on 01/17/13, until 3 hours later at 2300 hours;

2. notified a physician of low blood pressures from 01/17/13 at 2100 hours through 01/18/13 at 0830 hours;

3. obtained a physician's order for four (4) 500 milliliter (ml) fluid challenges given by a nurse on 01/17/13 at 2300, 01/18/13 at 0000, 0300 and 0600; and

4. documented a verbal order received from Dr. #1 indicating that Dr. #2's orders take precedence on 01/17/13; and correctly documented verbal orders received from Dr #2 according to policy.

Findings include:

The hospital policy titled Assessment-Reassessment required: "...Patients receiving inpatient services will have...appropriate follow-up assessments based upon their individual needs...."

1. Patient #4 was admitted on 01/10/13 with the following diagnoses: recent severe Clostridium difficile colitis, status post total colectomy and ileostomy; complex right hip wound; wound anterior abdominal wall; skin rash, likely related to allergic reaction to intravenous antibiotics; acute kidney injury, acute anemia and recent septic arthritis of the right hip.

On 01/17/13 at 1945 hours, the nursing narrative documentation included the following: "...Pt resting in bed. Assessment complete. Denies pain; Pt pale. Wounds C/D/I (clean/dry/intact). (No) distress. Dr (#2) in to see pt...."

01/17/13 at 2000 hours, the vitals signs were: Blood Pressure (BP) 76/57, Pulse (P) 94, Respirations (R) 24, Temperature (T) 97.0.

The next BP's documented are three hours later at 2300 hours: BP 102/60, 88/42, 86/56 (the blood pressures are listed on a flowsheet with columns and no exact times are documented for each reading).

Nursing did not reassess the Pt #4's BP for three hours after a BP of 76/57 was obtained.

The Nursing Manager confirmed on 05/17/13, during Pt #4's medical record review, that nursing did not document another BP for 3 hours after a reading of 76/57 and the expectation is that nursing would have rechecked the BP and documented the findings.

2. Patient #4's BP readings for 01/18/13 were as follows (the blood pressures are listed on a flowsheet with columns and no exact times are documented for each reading):

0000 hours BP 86/45;

0500 hours BP 95/39, 90/43; and

0600 hours BP 64/40; 71/57, 80/60, and 84/41.

Nursing did not document contacting a physician regarding Pt #4's BP on 01/18/13, from 0000 through 0600 hours.

The Nursing Manager confirmed on 05/17/13, during Pt #4's medical record review, that nursing did not document notifying a physician of low BP readings obtained from 0000 through 0600 hours. She confirmed it was the hospital's expectation that nursing would notify a physician of low BP readings and document the notification.

3. The hospital policy titled Medication Administration required: "...Requirements For A Valid Order...Individuals who...administer drugs shall do so only upon the order of a practitioner...."

Nursing documentation for Pt #4's intravenous (IV) fluid intake on page 6 of 8, of the 24-Hr Care Record, for 01/18/13 included the following:

2300 hours; 500 milliliters (ml) fluid bolus;

0000 hours; 500 ml fluid bolus;

0300 hours; 500 ml fluid bolus; and

0600 hours; 500 ml fluid bolus.

Review of the narrative nursing notes on 01/18/13 included the following:

0400 hours: "...BP (down) Fluid bolus started 500 ml p (after) u/o (urinary output) < (less than) 30 ml...."

Review of the physician orders for 01/18/13, from 0000 through 0600 hours, was conducted. No physician orders for a fluid bolus were documented.

The Nursing Manager confirmed on 05/17/13, during Pt #4's medical record review, that nursing did not document notifying a physician and obtaining an order for the normal saline fluid boluses administered to the patient. She confirmed it was the hospital's expectation that nursing would obtain a order for the fluid boluses.

4. The hospital policy titled Order Transcription required: "...If a question regarding cancellation of previous orders arises, an RN or LPN must obtain further clarification from the physician...."

Physician #1 (attending) saw Pt #4 on 01/17/13 and dictated a progress note at 1823 hours. Physician #1 ordered a Computerized Axial Tomography (CT) scan of the abdomen and pelvis Stat on 01/17/13. The order was not timed, however, nursing noted the order at 1637 hours.

Review of the physician's order sheet dated 01/17/13 and 01/18/13 included the following sequential orders:

01/17/13 at 2100 hours: "...Do CT A/P (abdomen and pelvis) c (with) PO (oral)/ IV (intravenous) contrast stat...V.O. (verbal order) Dr. #2 (Infectious Disease) (signed by) Employee #18 (Charge Nurse)...." On this order the word "stat" has a line written through it with a different pen from the rest of the order, and says "error." No initials or name is written by the word "error."

01/18/13 at 0445 hours: "...12 (hour) Resp (respiratory) chart check...."

01/18/13 at 2400 hours: "...T.O. (telephone order) Dr. #2 Culture urine, place new foley catheter, ML (midline) abdominal incision, ileostomy material...."

01/18/13 at 0700 hours: "...12 (hour) chart check...."

01/17/13 at 2100 hours: "...Don't CT A/P PO/IV contrast stat but may do it in the AM...VO Dr #2, signed Employee #18 (Charge Nurse)...."

During a telephone interview with Employee #18 on 05/17/13 at 1450 hours, he explained that he saw Dr #1 and that Dr. #1 told him to follow Dr #2's directions regarding the CT scan. He was asked if he wrote those directions from Dr. #1 and he explained he doesn't always document that he talks with doctors. He was asked if the second verbal order from Dr. #2 was a late entry and he could not remember. He also could not remember if he drew a line through the first order's "stat" and wrote "error."

The Nursing Manager confirmed on 05/17/13, during Pt #4's medical record review, that nursing Employee #18, must have written the second order as a "late entry," but did not indicate that it was a late entry. She confirmed the word STAT on the first order should not have had a line drawn through it with "error" added without clarification. She confirmed Employee #18 should have written Dr. #1's verbal order to follow Dr. #2's order regarding the CT scan.