HospitalInspections.org

Based on staff interviews, review of medical records and employee files, the hospital failed to ensure that all applicable State laws were adhered to when the hospital allowed 5 of 5 (J, HH, II, JJ and KK) Emergency Medical Technicians-Paramedic (EMT-Ps) to work under their State EMT-P licensure while performing hospital based care without hospital training or competency; the hospital allowed EMT-Ps to perform direct patient care tasks however, failed to ensure EMT-P ' s were on the Wisconsin caregiver registry; and the hospital failed to ensure 23 of 23 (F, G, H, I, Q, R, S, T, U, V, W, X, Y, Z, AA, BB, CC, DD, EE, FF, GG, LL and MM) Registered Nurses (RNs) who performed tasks in the hospital, had formal education and training to ensure the tasks were performed in a safe manner, or competencies to reflect performance was safe and effective.

Findings include:

The hospital allowed 5 of 5 (J, HH, II, JJ and KK) EMT-Ps to work under their EMT-P State licensure that allows them to work independently in a pre-hospital, however are independently performing in-hospital emergency response to codes and emergencies without Medical Staff oversight and without verifying EMT-Ps education and training skill level or conducting in-hospital competency to ensure practice was conducted per hospital Policy and Procedure (P&P). A 0023

The hospital allowed 5 of 5 (J, HH, II, JJ and KK) EMT-Ps to perform patient cares (nurse aid work) without training, education or competency to ensure performance for all in-hospital work was done per hospital policy & procedure. A0023

The hospital allowed 5 of 5 (J, HH, II, JJ and KK) EMT-Ps to perform patient cares (nurse aid work) without being on the Wisconsin caregiver registry. A0023

The hospital failed to ensure 23 of 23 (F, G, H, I, Q, R, S, T, U, V, W, X, Y, Z, AA, BB, CC, DD, EE, FF, GG, LL and MM) Registered Nurses (RNs) had qualifications, training and education requirements to conduct ventilator specific cares however the hospital allowed them to perform ventilator suctioning. A0023

The cumulative effect of these systematic failures resulted in the hospitals inability to ensure compliance with State laws.

Based on observations, staff and patient interviews, and review of pertinent patient records, policies and employee files, the hospital failed to have an effective governing body responsible for the conduct of the hospital when they allowed staff to work outside their scope of practice (23/23 Registered Nurses (RNs), and 5/5 Emergency Medical Technicians-Paramedics (EMT-Ps). The hospital failed to protect 7/7 patients' rights on 2 south nurses unit when continuous monitoring equipment was installed and being used in patients rooms. The hospital failed to have a structured and effective nursing service.

Findings include:

The hospital failed to comply with state law by allowing EMT-Ps to work in the hospital without hospital training, without hospital designated employee oversight and without the EMT-Ps being on the Wisconsin Caregiver Registry. (See A023)

The hospital failed to ensure all patient rights are protected by not obtaining consent for continuous video monitoring. (See A115)

The hospital failed to ensure all nursing services are provided by trained nurses; failed to ensure nurses establish and update patient care plans; and, failed to provide sufficient numbers of staff to ensure patient care is appropriate. (See A385)


The cumulative effect of these systemic failures resulted in the hospital's inability to have an effective Governing Body which affects all hospital patients.

Based on patient and staff interviews, review of medical records, and observations the hospital failed to provide 7 of 7 patients with potential of 19 patient ' s personal privacy in their patient rooms, when the hospital conducted continuous monitoring and failed to inform each patient or obtain consent to video monitor while in hospital.

Findings include:

The hospital failed to inform each patient prior to admission that the hospital had installed cameras in each patient room on the south unit and that the hospital staff would be continuously monitoring, each patient (potentially 19) current census 7. The monitor was located behind the nurse ' s station, which is not secured or locked to prevent ancillary staff from viewing patients during cares and the hospital failed to have a policy. (A0143)

Hospital failed to obtain consent from patients to allow continuous video monitoring of patients while in their rooms and during personal cares that included toileting and bathing. (A0131)

Cumulative effect of these systematic failures resulted in the hospital's inability to provide all patients of their rights to privacy while being treated as a patient at their facility.

Based on record review, observation, and staff interviews the hospital failed to have a well organized nursing service that defined authoritative structure. This was evidenced by inadequate staffing patterns, inadequate delivery of care, lead nursing personnel not qualified to perform lead duties and key nursing personnel unaware of which ancillary staffs were capable of performing specific patient care duties.

Findings include:

1. The Chief Nursing Officer (CNO) D failed to have clearly defined competency based job descriptions or policy and procedures (P & P) that show the authoritative structure of nursing services for 23 of 23 Registered Nurse (RN) (F, G, H, I, Q, R, S, T, U, V, W, X, Y, Z, AA, BB, CC, DD, EE, FF, GG, LL, and MM) responsible for supervisory delegation of ancillary nursing staff that includes Certified Nursing Assistants (CNA) and Emergency Medical Technicians (EMT) (A386)

Charge nurses 5/5 (Charge RN ' s V, X, Z, CC, and MM) have not been trained and educated to understand the authoritative flow of the nursing services or their required duties as charge nurse. (A386)

Registered Nurses were documenting on nursing competencies and skill proficiencies that were not performed. (A386)

RN staff 23/23 (F, G, H, I, Q, R, S, T, U, V, W, X, Y, Z, AA, BB, CC, DD, EE, FF, GG, LL, and MM) is unaware of what specific tasks their ancillary staff could or could not perform. (A386)

2. The CNO D failed to ensure the hospital had an adequate number of staff to meet the patients ' needs. (A392)

3. The RN staff failed to supervise the hospitals ancillary staff to ensure delegated tasks were performed, monitored and documented per hospitals P & P. (A395)

4. The hospital failed to initiate and update care plans prior to admission despite receiving medical and nursing information to make a determination of admission and revise plans of care to ensure they meet each patients needs (A396)

5. The CNO D failed to ensure 23 of 23 RN 's (F, G, H, I, Q, R, S, T, U, V, W, X, Y, Z, AA, BB, CC, DD, EE, FF, GG, LL, and MM) responsible for assigning and delegating tasks per patient needs were aware of the specialized qualifications and competence of the nursing staff available. (A397)

The cumulative effects of these systematic failures, created an unorganized nursing services that failed to meet each patients needs that were dependent on their care.

Based on staff interviews, review of medical records, employee files, the hospital failed to ensure that all applicable State laws were adhered to when the hospital allowed 5 of 5 (J, HH, II, JJ and KK) Emergency Medical Technicians-Paramedic (EMT-Ps) to work under their State EMT-P licensure while performing hospital based care without hospital training or competency;
the hospital allowed 5 of 5 (J, HH, II, JJ and KK) EMT-Ps to perform patient care tasks however, failed to ensure EMT-P ' s were trained and competent, and were never placed on the caregiver registry; and
the hospital failed to ensure 23 of 23 (F, G, H, I, Q, R, S, T, U, V, W, X, Y, Z, AA, BB, CC, DD, EE, FF, GG, LL and MM) Registered Nurses (RNs) performing tasks in the hospital, had formal education or training to ensure the tasks were performed in a safe manner, or competencies to reflect performance was safe and effective.

Findings include:

The Wisconsin Nurse Practice Act provides the following:

N 6.03(2)(b) Accept only those delegated medical acts for which the R.N. is competent to perform based on his or her nursing education, training or experience;

N 6.03(3) SUPERVISION AND DIRECTION OF DELEGATED NURSING ACTS. In the supervision and direction of delegated nursing acts an R.N. shall:
N 6.03(3)(a) Delegate tasks commensurate with educational preparation and demonstrated abilities of the person supervised;

These provisions of the Nurse Practice Act were not followed as evidenced by:
#1
On 06/22/11 between 8:50 a.m. and 9:55 a.m. during a tour of the 2 South Nursing unit Chief Nursing Officer (CNO) D and Director of Quality Assurance (QA) C told Surveyors #22198 and 29963 that the hospital employed Emergency Medical Technicians-Paramedics to respond to emergencies and codes.

CNO D and Director of QA C told Surveyors #22198 and #29963 EMT-P were licensed on the Emergency Medical Service (EMS) national registry and in the State of Wisconsin. CNO D and Director of QA C confirmed 5 of 5 (J, HH, II, JJ and KK) EMT-Ps worked under their own license, and reported directly to CNO D without medical director oversight.

On 06/22/11 at 3:45 p.m. Surveyor #22198 during an interview, reviewed the findings from the employee file review for 1of 5 (J) EMT-Ps with CNO D and Director of QA C.

On 06/23/11 at 12:30 p.m. during a telephone interview, the State of Wisconsin Director of Emergency Medical Services (EMS) services. NN confirmed to Surveyor #22198, EMTs are licensed to work in a pre-hospital arena and that is all their EMT licensure will cover no matter what level of EMT they are.

State of Wisconsin Director of EMS services NN told Surveyor #22198, that if a hospital chooses to employee EMTs, the hospital is responsible for the oversight of the EMTs work, and that the EMT license is not transferable.

On 06/23/11 at 12:00 p.m. during a telephone interview, Medical Director E told Surveyors #22198 and 29963, that as Medical Director, E was not responsible for the oversight of the EMT-Ps that worked in the hospital.

Medical Director E told Surveyors EMT-Ps worked under their EMT-P State licensure.

Excerpt from the hospital's EMT job description and Performance Evaluation;
" Key Responsibilities:
4. Performs first responder care inside the facility within the scope and training of the National Registry of Emergency Medical Technicians and the State of Wisconsin EMS scope of Practice and Critical Care Paramedics guidelines. "

During an interview on 06/22/11 at 3:45 p.m. CNO D and Director of QA C confirmed to Surveyor #22198, EMT-P Js employee file did not contain the hospital based formal education and training.

CNO D and Director of QA C confirmed to Surveyor #22198, J had not received hospital based Emergency response competencies to ensure care was provided in a safe and effective manner based on the hospital's policies and procedures to ensure regulatory requirement compliance.

CNO D and Director of QA C confirmed to Surveyor #22198, that 5 of 5 EMT-Ps (J, HH, II, JJ and KK) employee files did not have hospital based training and education.

During an interview on 06/23/11 at 4: 15 p.m. Director of QA C confirmed to Surveyor #22198 and Surveyor #29963 the facility was not aware that the EMTs State license would not cover them while working inside a hospital.

#2
On 06/22/11 between 8:50 a.m. and 9:55 a.m. during a tour of the 2 South nursing unit Chief Nursing Officer (CNO) D and Director of Quality Assurance (QA) C told Surveyors #22198 and 29963 that Emergency Medical Technicians-Paramedics (EMT-P) employed by the hospital performed emergency response, patient care duties and assisted the nursing staff.

On 06/23/11 at 11:35 a.m. during a telephone interview EMT-P J confirmed to Surveyors #22198 and #29963 that as lead EMT-P he trains new EMT hires at the hospital.

EMT -P J confirmed to Surveyors #22198 and #29963 that EMTs are allowed to do patient care including nurse aid tasks described by J as turning and repositioning, transfers, and help cleaning up patients.

EMT-P J told surveyors he does what ever nursing staff asks him to do.

EMT-P J told Surveyors #22198 and #29963 that in addition to the telemetry and first responder duties he also conducts medication pass, IV insertion and IV medication administration, as well as tube feedings.

On 06/22/11 at 3:45 p.m. Surveyor #22198 during an interview, reviewed the findings from the employee file review for 1of 5 (J) EMT-Ps with CNO D and Director of QA C.

Excerpts from the hospital's EMT job description and Performance Evaluation; " Key Responsibilities:
2. Serve as the telemetry technician for the hospital will observe telemetry monitors at the nursing unit for changes in rate, rhythm, vital signs or other critical care monitors and serve as a resource for treatment of acute changes or conditions
4. Performs first responder care inside the facility within the scope and training of the National Registry of Emergency Medical Technicians and the State of Wisconsin EMS scope of Practice and Critical Care Paramedics guidelines
5. Will provide assistance to the clinical team including delivery of medications as outlined in the Wisconsin Paramedics Medication List
6. Assists in delivery of direct patient care in the Emergency Department/Clinic high observation unit, hospital, residential and school programs
7. Performs CPR based on established standards and assists during code/Dr. Stat "

Excerpts from EMT-P " Qualifications: "
1. " Skills, Knowledge and Abilities: ACLS, PALS intubation, medication delivery, Phlebotomy, physical assessment, vital signs, telemetry, first aide, computer application/documentation.
3. Licensure: Current license by the National Registry for EMT-P current license by the State of Wisconsin as EMT-P, current CPR, ACLS and PALS "
Detailed information and regulation can be obtained from:

On 06/23/11 at 12:30 p.m. during a telephone interview, the State of Wisconsin Director of EMS services NN confirmed to Surveyor #22198, that EMTs are not trained to administer all medication, but rather emergency medication.

State of Wisconsin Director of EMS services NN confirmed to Surveyor #22198, that if a facility were to hire EMTs at any level it is up to the facility to ensure each EMT received hospital based training to ensure the EMT was competency trained and tested to provide hospital based cares.

The State of Wisconsin Director of EMS services NN confirmed to Surveyor #22198, that EMTs are not trained to do tube feedings or do nurse aid cares.

On 06/23/11 at 12:15 Surveyor #22198 called the Office of Caregiver Quality (OCQ) to determine what defines a caregiver under the Wisconsin law and are EMTs included in the caregiver law as nurse aids if they are providing direct patient cares.

OCQ OO confirmed to Surveyor #22198 that an EMT doing direct patient care as described by EMT-P J and CNO D is considered " direct patient care " , that EMTs working in this capacity should have nurse aid training and be placed on the registry.

OCQ OO told Surveyor #22198, that EMTs although skilled in the work they perform for EMS services, does not receive training like; restorative care or dementia training.

On 06/22/11 at 3:45 p.m. CNO D and Director of QA C confirmed that the hospital had not provided any formal training or education to the EMTs to ensure care was provided based on hospital regulation requirement or hospital P&P.

On 06/22/11 at 3:45 p.m. CNO D and Director of QA C confirmed that the competency assessment was based off of the EMT licensure skill, and not the in-patient hospital setting.

On 06/22/11 at 3:45 p.m. CNO D and Director of QA C confirmed that the hospital had not provided any additional hospital based training and education to perform medication pass, a duty assigned to licensed nursing personnel.

CNO D and Director of QA C confirmed that EMTs had not been trained to perform tube feedings. CNO D and Director of QA C confirmed that the hospital was currently allowing EMTs to work outside the licensure scope of practice.

During an interview on 06/23/11 at 1:19 p.m. Human Resource (HR) Director B and Director of QA confirmed 5 of 5 EMT-P files failed to comply with State Caregiver law under Chapter DHS 146.40 that defines a caregiver and Chapter DHS 129 that defines the program training and testing for nurse aids, medication aids and feeding assistants. This can be obtained from

Human Resource (HR) Director B and Director of QA confirmed that 5 of 5 (J, HH, II, JJ and KK) EMT staff were performing nurse aid and direct patient care, however failed to be current on the caregiver registry as required by State law.

#3
On 06/22/11 Registered Nurse (RN) employee files were reviewed for RN F, G, H and I by Surveyor #22198, and findings reviewed with CNO D at 3:45 p.m., to confirm RNs F, G, H and I's competencies included ventilator care, tracheotomy suction and Peritoneal dialysis and emergency response to behavioral emergencies.

RN Fs competency defined F was competent by observation (signed off by RN H) to perform endotracheal suctioning, conduct ventilator care and able to identify meaningful ventilator alarms. Emergency procedures were documented as n/a (not applicable).

On 06/23/11 at 8:30 a.m. during a telephone interview, RN F confirmed to Surveyors #22198 and #29963, that F had never received formal training on ventilator care, alarms or endotracheal suction from the hospital. RN F confirmed F was not qualified or competent to perform these tasks.

RN F confirmed to Surveyors #22198 and #29963 that responding to all emergencies was mandatory, and RNs are required to be competent. F had no explanation as to why Fs record was marked n/a, however confirmed she had signed the form as being complete.

When Surveyor #22198 asked RN F how the RNs knew which nursing staff were competent to perform specific nursing tasks? RN F confirmed the hospital has no way of providing the RNs who are responsible to delegate nursing tasks this information. RN F told Surveyors it is assumed if nursing staff have been cleared to work independently they are competent to perform all delegated tasks.

RN Gs competency defined G was competent by observation (signed off by RN H) to perform endotracheal suctioning, conduct ventilator care, identify meaningful ventilator alarms and set up and monitor Peritoneal dialysis.

On 06/23/11 at 9:00 a.m. during a telephone interview, RN G confirmed to Surveyors #22198 and #29963, that G had never received formal training on ventilator care, alarms, endotracheal suction, peritoneal dialysis set up or monitoring from the hospital.

RN G confirmed G had done endotracheal suctioning in the hospital.

RN G confirmed G was not qualified or competent to perform these tasks. RN G told Surveyors the hospital staff does not do dialysis, that service in contracted out, and could not explain why G was signed off as competent.

When Surveyor #22198 asked RN G how the RNs knew which nursing staff were competent to perform specific nursing tasks? RN G confirmed the hospital has no way of providing the RNs, who are responsible to delegate nursing tasks this information. RN G told Surveyors it is assumed if nursing staff have been cleared to work independently they are competent to perform all delegated tasks.

RN I's competency defined RN I was competent by observation (signed off by RN H) to perform endotracheal suctioning, conduct ventilator care, identify meaningful ventilator alarms, set up and monitor Peritoneal dialysis.

On 06/23/11 at 9:25 a.m. during a telephone interview RN I confirmed RN I had not received hospital based training or competencies.

RN I stated RN I felt qualified to perform suctioning and ventilator care based on training and competencies from other facilities RN had worked at. RN I confirmed RN I was suctioning ventilator patients at the hospital.
However, RN I confirmed no training or education was in RN I's file to confirm ventilator specific qualifications.

RN I confirmed to surveyors the hospital staff does not do dialysis, that this service was contracted out, and could not explain why he was checked off as observed to be competent with peritoneal dialysis specific tasks.

When Surveyor #22198 asked RN G how the RNs knew which nursing staff were competent to perform specific nursing tasks? RN G confirmed the hospital has no way of providing the RNs, who are responsible to delegate nursing tasks this information. RN G told Surveyors it is assumed if nursing staff have been cleared to work independently they are competent to perform all delegated tasks.

RN H's competency defined H was competent by observation (signed off by RN S) to perform endotracheal suctioning, conducts ventilator care and identifies meaningful ventilator alarms.

On 06/23/11 at 10:00 a.m. during an in-person interview, Surveyor #22198 asked RN H what training, education or guidance had H received from the hospital to conduct observations and " sign off " competencies for ventilator care, suctioning and peritoneal dialysis for RNs F, G and I?

RN H confirmed the hospital had provided no guidance, training or education. RN H told Surveyors " I am not competent to perform these tasks " .

RN H acknowledged H should not have been signing off competencies on tasks H was not competent to perform.

When Surveyor #22198 asked RN H how the RNs knew which nursing staff were competent to perform specific nursing tasks? RN H confirmed the hospital has no way of providing the RNs, who are responsible to delegate nursing tasks this information. RN H told Surveyors it is assumed if nursing staff have been cleared to work independently they are competent to perform all delegated tasks.

On 06/22/11 at 3:45 p.m. CNO D and Director of QA C confirmed to Surveyors #22198 and #29963, that the hospital has had 5 different Chief Nursing Officers (CNOs) in the past 2 years.

CNO D confirmed that D was aware that education, training and competencies were non-compliant for the 4 RN (F, G, H and I) employee files Surveyor #22198 reviewed.

CNO D confirmed that all RN staff 23 of 23 (F, G, H, I, Q, R, S, T, U, V, W, X, Y, Z, AA, BB, CC, DD, EE, FF, GG, LL and MM) files failed to comply to ensure staff were qualified, and trained.

CNO D confirmed that CNO D, after identifying education and training was non-compliance, failed to stop all nursing staff 23 of 23 (F, G, H, I, Q, R, S, T, U, V, W, X, Y, Z, AA, BB, CC, DD, EE, FF, GG, LL and MM) RNs from performing tasks they were not qualified to perform.

CNO D confirmed that, CNO D had not implemented protocol to ensure 23 of 23 (F, G, H, I, Q, R, S, T, U, V, W, X, Y, Z, AA, BB, CC, DD, EE, FF, GG, LL and MM) RNs that were responsible for the nursing cares of every patient admitted to the hospital and the day to day nursing delegation had received complete or accurate information to make delegation determination per the Nursing practice act in Chapter N 6.

State of Wisconsin Nurse Practice Chapter (N6) can be obtained at:

Based on medical record review, observation and interview, the hospital failed to provide personal privacy to 7 of 7 (2, 3, 4, 5, 10, 11, and 12) patients, with potential for a total of 19 patients on 2 south being effected, by not informing patients that they would be continually video monitored while in the hospital.

Findings include:

The census on 2 South 6/22/11 through 06/24/11 was 7 (2, 3, 4, 5, 10, 11, and 12).

During the initial tour of 2 South unit on 06/22/11 at 8:45 a.m. a video camera monitor was noted in nurse ' s station that could be viewed by anyone inside the nurses desk area. The nurse ' s station did not have a door or lock to prevent breach to this area where the video screen showed continuous monitoring of all their patients.

Video monitor showed continuous monitoring of 7 of 7 (2, 3 4, 5, 10, 11, and 12) patients with the potential for monitoring 19 (number of patient beds on 2 South).

From 06/22/11 through 06/24/11 during the survey, review of 7 of 7 (2, 3 4, 5, 10, 11, and 12) medical records confirmed patients did not consent to continuous video monitoring.

On 6/24/11 at 11:15 a.m. Surveyor #22198 was at the nursing station. No nursing staff were present at the nursing station. Housekeeper O entered the nurse ' s station and started cleaning. Housekeeper O was observed viewing the video screen.

On 06/24/11 Surveyor #22198 interviewed 2 patients that staff identified as alert and oriented and able to provide reliable and accurate information.

On 06/24/11 at 12:00 Surveyor #22198 asked Patient #3 if #3 was aware that the hospital had cameras that allowed staff to continuously monitor #3 in her room? Patient #3 replied " no " .

On 06/24/11 at 12:05 p.m. Surveyor #22198 asked Patient #5, if #5 was aware that the hospital had cameras that allowed staff to continuously monitor #5 in her room? Patient #5 replied " no " . Patient #5 asked Surveyor, " Why would they need to do that? "

During an interview on 6/24/2011 at 11:30 am Director of Q A confirmed to Surveyors #29963 and #22198, that the hospital does not inform patients, and has no consent to ensure each patient is aware they are on continuous video monitoring.

Director of Q C confirmed the hospital has no policy regarding continuous video monitoring.

Based on medical record review, observation and interview, the hospital failed to provide personal privacy to 7 of 7 (2, 3, 4, 5, 10, 11, and 12) patients, with potential for a total of 19 patients being effected, by using continual video monitoring while at hospital without patient knowledge.

Findings include:

The census on 2 south 6/22/2011 through 6/24/2011 was 7 (2, 3, 4, 5, 10, 11, and 12) with the potential for monitoring 19 (number of patient beds on 2 south) however the hospital is licensed for 39 patients.

During the initial tour of 2 South unit on 6/22/2011 at 8:45 a.m., a video camera monitor was noted in nurse ' s station that could be viewed by anyone inside the nurses desk area. The nurse ' s station did not have a door or lock to prevent breach to this area where the video screen showed continuous monitoring of all their patients.

Video monitor showed continuous monitoring of 7 of 7 (2, 3, 4, 5, 10, 11, and 12) patients.

From 06/22/2011 through 6/24/2011 during the survey, review of 7 of 7 (2, 3, 4, 5, 10, 11, and 12) current in-patient medical records confirmed patients did not consent to conduct continuous video monitoring of them.

On 6/24/2011 at 11:15 a.m. Surveyor # 22198 was at nursing station. No nursing staff were present at the nursing station. Housekeeper O was observed viewing the video screen.

Surveyors #22198 was able to observe the monitor as Housekeeper O was viewing and saw Patient #10 naked receiving a full bed bath, without any cover to body parts not being washed.

Certified Nursing Assistant (CNA) P came to the nurse station at 11:30 a.m., and Surveyor #22198, asked CNA-P about what was happening on the monitor.

CNA-P confirmed that Patient #10 should not be lying totally naked during a bed bath. CNA-P confirmed nurse aid staff are trained to preserve patient's dignity, and to expose only the part of the body that is currently being washed.

CNA-P confirmed that all hospital staff are allowed behind the nursing desk, for example, Physical Therapy, Social Workers, Housekeeping, and Maintenance.

On 6/24/2011 at 11:30 a.m. Surveyor #29963, viewed on video monitor, pt # 4 being assisted by 2 staff onto the commode placed next to bed.

On 6/24/2011 Surveyor #22198 interviewed 2 patients that staff identified as alert and oriented and able to provide reliable and accurate information.

On 6/24/2011 at 12:00 p.m. Surveyor #22198 asked Patient #3 if #3 was aware that the hospital had cameras that allowed staff to continuously monitor #3 in her room. Patient #3 replied "no" .

On 6/24/2011 at 12:00 Surveyor #22198 asked Patient #5 if #5 was aware that the hospital had cameras that allowed staff to continuously monitor #5 in #5s room. Patient #5 replied "no" . Patient # 5 asked surveyor, "why would they need to do that?"

During an interview on 6/24/2011 at 11:30 a.m. Director of Q C confirmed to Surveyor #29963 and #22198 that the hospital does not inform patients that they are on continuous video monitoring and the hospital has no policy regarding continuous video monitoring.

Based on observations, review of policy and staff and patient interviews the hospital failed to have a staffing matrix that would identify both the number of patients as well as acuity of the patient load to determine staffing patterns. Current census during this survey was 7, observations noted it effected 6 of 7 (#2, #3, #5, #10, #11 and #12) patients who were not assisted out of bed on 06/22/11 when a scheduled staff failed to remain working for the day shift.

Findings include:

On 06/22/11 Surveyors #22198 and #29963 noted 6 of 7 patients still in bed during the tour of 2 South Nurses Unit from 8:45 a.m. through 10:00 a.m.

During an interview before leaving the 2 South Nursing Unit at 9:55 a.m. Chief Nursing Officer (CNO) D told Surveyors #22198 and #29963 that the hospital does not use a nursing matrix to determine staffing. CNO D told Surveyors that if patient census is 10 and below, the hospital has 2 Nurses (Registered Nurses (RN) or Licensed Practical Nurses (LPNs) and 2 Certified Nursing Assistants (CNA) and that staffing patterns were not based on acuity of patients, only census.

O6/22/11 interviews with Patients #2, #3 #5 confirmed that staff had told them they were short one staff today because of a call in.

Patient #2 confirmed she had no restrictions that prevented her from getting out of bed, and noted she had not been out of bed for 2 days. Patient #2 was a total assist and needed 2 staff members to transfer and the use of an EZ stand lift.

Patient #2 was supposed to be out of bed per the Interdisciplinary Team (IDT) Plan of Care.

Patient #2 mentioned to Surveyor #22198 that the staff were putting her on the bed pan for elimination of both bowel and bladder.

A medical record review confirmed no documentation in Patient #2s medical record supported this mode of elimination.

Medical record review documentation supported Patient #2s statement regarding not being out of bed for several days. Patient #2 also stated that she had complained about the lift the staff decided to use to assist Patient #2 out of bed because of the additional pain it caused Patient #2.

Patient #3 confirmed #3 had no restrictions that prevented her from getting out of bed, and noted #3 had not been out of bed for several days.

06/23/11 a medical record review confirmed Patient #3 was a total assist and needed 2 staff members to transfer and the use of a Hoyer lift.

Patient #3 was suppose to be out of bed per the IDT Plan of Care.

Patient #3s care plan did not have a bowel program or plan of care, and staff were rolling Patient #3 and placing her on a bed pan for both bowel and bladder elimination.

At 3:35p.m. Surveyor #22198 returned to the floor to find 6 of 7 Patients (#2, #3, #5, #10, #11 and #12) were still in their beds. Patients #2 and #3 confirmed up until this time, they had not been out of bed.

RN interview with F, G, H and I on 06/23/11 between 6:30 and 10:00 a.m. confirmed the facility worked short staff, and work often got delayed, or shifted to another day or another shift.

RNs (F, G, H and I) responsible for staffing when administration was not on site thought staffing patterns changed when patient census was 7 patients or more, and confirmed patient acuity was not incorporated into staffing patterns..

RN H told Surveyors currently all 6 of 7 patients on 2 South Nursing units were total assist which would also be a variable in patient acuity for staffing patterns.

On 06/23/11 at 3:45 p.m. CNO D and Suveryor #22198 had an interview that included a review of the current policy entitled: "Staffing Needs and Assessment" lasted reviewed and revised 6/10.

CNO D and Suveryor #22198 noted the policy defined the use of "nursing acuity system" (matrix) as a part of policy for staffing needs assessment.

CNO D confirmed to Surveyor #22198, that the hospital had no nursing matrix (acuity system) currently used to determine staffing patterns.

The hospital failed to produced an acuity system (matrix) per nursing standards of practice during the 3 day survey.

CNO D confirmed the facility was working 1 staff below average on 06/22/11.

Based on record review, observation, and staff and employee interviews, the nursing services failed to initiate, update and follow current nursing care plans for 9 out of 10 patients (#1, 2, 3, 5, 6, 7, 8, 9, and 10) to ensure all the needs of the patients were met. The hospital failed to follow policy and procedure established for monitoring weights in 8 out of 10 (#1, 2, 3, 5, 6, 7, 8, and 9) patients.

Findings include:

On 06/22/2011 between 8:50 a.m. and 9:55 a.m. during a tour of the 2 south Nursing unit with surveyor #29963 and #22198, 1 of 7 patients was noted to be out of bed and sitting in chair in room.

On 06/22/2011 at 9:20 a.m. surveyor # 29963 and #22198, interviewed Director of QA C, he stated that the hospital employs 4 nurses who are regionally placed at other hospitals to assess patients needs to see if they meet criteria to be admitted to this hospital. Information is then brought back to hospital for physician and wound care nurse to review information.

Director of QA C and CNO D stated that care planning is initiated upon admission by nurses and other interdisciplinary members, care plans are not initiated prior to admission as this information is not shared with staff working on the unit per interview with surveyor # 29963 and #22198 on 06/22/2011 at 9:20 a.m.

Policy on nursing care plans provided to surveyor # 29963 from Director of QA C on 6/23/2011 at 3:30 p.m. Policy was implemented 4/10 and last revised on 10/10. Policy states that the purpose is to ensure that individualized patient centered care is provided based on individual patient treatment goals.

I.A.1. " The admission assessment is initiated by the RN and must be completed within 24 hours of admission " II.A.1. " An individualized nursing care plan which includes patient education is developed for each patient, reviewed and revised as needed at least every 24 hours " . 1. Goals are mutually set through the collaborative efforts of the RN and patient and or designee, if unable to participate; this must be documented in the nursing progress notes " .

Policy on weights was provided to surveyor # 29963 from Director of QA C on 6/22/2011 at 4:00 p.m. Policy was implemented 1/10 and revised on 10/10. Subtitle of purpose states the following: " Accurate weight measurement is critical to nutrition assessment of patients in long term acute care. Inaccurate measurements can affect the plan of care and nutritional interventions. "

Subtitle of policy states the following: " Patients weight is to be obtained immediately upon admission as part of the nursing admission assessment, at least weekly thereafter admission, pre and post dialysis or as ordered by the physician. "

Under procedure #5 states the following: "All weights are to be compared to the last weight obtained. If a variance of 5 pounds or more is noted, it is ultimately the responsibility of the patients' nurse to direct the nursing aides to have the patient reweighed."

Policy does not include guidelines for RN ' s as when to update MD with weight changes. Per interview on 06/22/2011 at 3:45 p.m. with Registered Dietitian (RD) PP, she stated that nurses call to notify dietitian with 5 pound weight gain or loss.

On 06/23/2011 at 12:00 p.m. with surveyor #29963 and #22198, MD E stated " that nurses document weights but do not call when changes are noted. I do not know what the hospital protocol is " .

On 06/22/2011 at 10:30 a.m. surveyor #29963 reviewed patient #1 closed medical record. Patient #1 was admitted to this hospital on 04/13/2011 due to respiratory failure and was a ventilator dependent patient with tracheotomy. Patient was fed by tube feeding, did not eat anything by mouth.

Patient #1 was dependent with all bed and chair mobility and did not have any activity restrictions noted per physician orders. 7 out of 41 days patient #1 was left in bed from 9:00 a.m. to 11:00 p.m. and 1:00 p.m. - 2:00 p.m. 16 out of 41 days patient #1 was left in bed on p.m. shift per patient progress report.

Admission weight on 04/13/2011 was 173.3 pounds. Orders on admission were to weigh every Monday and Friday. No weight obtained on 4/15/2011 per MD order. Next weight obtained was on 04/17/2011, which was 183.4 pounds. Weight on 04/22/2011 was 178.6 pounds. Weight on 04/24/2011 was 179.9 pounds. No re-weighs documented.

On 04/28/2011 chest x-ray showed diagnosis of congestive heart failure (extra fluid surrounding the heart or in extremities). On 5/3/2011 MD ordered weights to be done daily. 8 out of 23 days had no weights completed. Diuretic (used to get rid of extra fluid around heart or lower extremities) was stopped at this time. No further treatment for congestive heart failure at this time but patient continued to lose 22 pounds.

Last weight obtained on 05/23/2011 was 155.4 pounds. (27 pound weight loss during hospitalization). No weight changes noted in nursing Progress notes. MD does not address weight loss in progress notes.

Interview with RD QQ on 06/22/2011 at 3:45 with surveyor #29963; RD QQ stated that weight loss in patient #1 was a therapeutic weight loss. Surveyor asked RD QQ how much weight was therapeutic for patient to lose per week and RD QQ stated 1-2 pounds per week (patient lost an average of 6 # per week once stable from congestive heart failure from 05/03/2011-5/23/2011).

MD E states that weights are recorded by nurses; changes are not called to MD per interview with surveyor #29963 and # 22198 on 06/32/2011 at 12:00 p.m.

These findings where confirmed with CNO D and Director of QA C on 06/23/2011 at 3:20 p.m. regarding patient #1.

On 06/23/2011 at 8:15 a.m. surveyor # 29963 reviewed patient # 6 closed medical records. Patient #6 was admitted to this hospital on 5/16/2011 due to respiratory failure and was a ventilator patient with tracheotomy.

Patient #6 was dependent with all bed and chair mobility and did not have any activity restrictions noted per physician orders. 12 out of 12 days, patient #6 was left in bed per patient progress report.

Patient #6 entered hospital with an order for every other day weights ordered on 05/16/2011. No admission weight obtained. Only weight recorded was on 5/22/2011 with a weight of 133.8 pounds. Patient was discharged on 05/27/2011.

These findings regarding patient #6 were confirmed with CNO D and Director of QA C on 06/23/2011 at 3:20 p.m.

On 06/23/2011 at 3:00 p.m. surveyor # 29963 reviewed patient # 7 closed medical records. Patient #7 was admitted to this hospital on 04/29/2011 due to respiratory failure and was a ventilator patient with tracheotomy.

Patient # 7 was dependent with all bed and chair mobility and did not have any activity restrictions noted per physician orders, only orders to turn every two hours for change of position. 10 out of 10 days, patient #7 was left in bed per patient progress report.

Patient #7 entered hospital with an order for every other day weights ordered on 04/29/2011. Admission weight recorded as 109.5 pounds. Other weight documented is 05/01/2011 of 108.4 pounds. No other weights obtained. Patient was discharged on 05/08/2011.

These findings regarding patient # 7 were confirmed with CNO D and Director of QA C on 06/23/2011 at 3:20 p.m.

On 06/23/2011 at 3:30 p.m. surveyor # 29963 reviewed patient # 8 closed medical records. Patient #8 was admitted to this hospital on 03/15/2011 for a surgical wound that required wound care.

Patient # 8 was independent in bed and chair mobility and did not have any activity restrictions noted per physician orders. 16 out of 44 days patient # 8 was documented as not being up in chair per patient progress report.

Patient #8 entered hospital with an order for every other day weights ordered on 03/15/2011. Admission weight recorded as 155.6 pounds. Ten (10) weights were not obtained per MD order while in hospital. Weight on 04/17/2011 was 149 pounds and weight on 04/20/2011 was 133 pounds, no re-weigh documented.

These findings for patient # 8 were confirmed with CNO D and Director of QA C on 06/23/2011 at 3:20 p.m.

On 6/24/2011 at 11:30 a.m. surveyor # 29963 reviewed patient # 9 closed medical records. Patient # 9 was admitted to this hospital on 03/02/2011 for respiratory failure and was a ventilator patient with tracheotomy.

Pt # 9 was dependent in bed and chair mobility and did not have any activity restrictions noted per physician order. 18 out of 55 days patient # 9 was documented as not being up in chair per patient progress report.

Patient #9 entered hospital with an order for weekly weights ordered on 03/02/2011. No admission weight obtained. Weight recorded on 03/10/2011 of 235 pounds. No weight recorded for week of 03/13/2011, or 03/27/2011. Weight on 03/20/2011 was 221.5 pounds, no reweigh noted. Weight on 04/17/2011 was 219.0 pounds and weight on 04/24/2011 was 210.4 pounds: no re-weigh noted.

These findings for patient # 9 were confirmed with Director of QA C on 06/24/2011 at 11:45 a.m.



On 6/24/2011 at 8:30 a.m. surveyor # 29963 reviewed patient # 10 medical records. Patient # 10 was admitted to this hospital on 06/17/2011 for respiratory failure and was a ventilator patient with tracheotomy.

Patient # 10 had a flow sheet hanging in room for every 2 hours repositioning and every hour rounds to be completed. Staff is to initial time slot when task is completed. Flow sheet with numerous time slots unsigned (on 6/20/2011, no initials from 7:00 a.m. -1:00 p.m. and on 6/23/2011, no initials from 9:00 am to 5:00 p.m.). This was confirmed with Director of QA C on 6/24/2011 at 10:55 a.m.

Surveyor #22198 on 06/23/11 between 3:00 p.m. and 4:10 p.m. reviewed in-patient medical records for Patient #2 and #3. The following was identified:

Patient #2 was admitted on 06/10/11.

Physician ' s admission order (06/10/11) requested weights every other day.
Weight on the day of admission was 229.
On 6/14/11 Patient #2s weight was 228. On 06/16/11 Patient #2's weight dropped 22 pounds (207) a 9.6% weight loss, no documentation was found to confirm nursing services had notified the physician or consulted the registered dietician. No re-weight was documented per the hospital P&P.

Per admission orders dated 06/10/11, Physical Therapy (PT) conducted a patient evaluation of 6/13. PT indicated Patient #2's was to be up with 2 assist. No restriction identified to prevent Patient #2 out of bed.

On 06/22/11 at 8:50 a.m. the nurse white board defined "EZ lift" was to be used that contradict the PT evaluation and the Interdisciplinary Team (IDT) Plan of Care.

The mechanical EZ lift utilizes a patient legs and arms in the process of getting a patient up.

On 06/22/11 at 9:05 a.m. in room 2061A Patient #2 was lying in bed and told Surveyor #22198, that #2 had not gotten out of bed for 2 days.

Patient #2 told Surveyor #22198 that it was too painful to use the EZ stand because her legs hurt and she had shoulders pain related to rotator cuff injury.

Patient #2's medical record confirmed Patient #2 had venous stasis ulcers, and peripheral insufficiency, and bilateral rotator cuff injury.

No re-assessment was documented, no documentation identified Patient #2s pain with the use of the EZ stand lift. No rationale was identified for leaving Patient #2 in bed.

On 06/23/11 at 10:00 a.m. during an interview RN H confirmed that Patient #2 should have been up and out of bed.

RN H told Surveyors #22198 and #29963, that H had conducted an " aggressive " bowel evacuation on Patient #2 including fecal extraction. RN H acknowledged gravity assists in having bowel movements; however nursing staff were not getting Patient #2 out of bed to have a bowel movement.

Patient # 3s was admitted on 06/13/11 for cellulites and Left Extremity (LE) ulcer. Physician ' s admission orders included weight every other day and up with assistance. IDT Plan of Care supported Patient #3 getting up.

No admission weight was documented for Patient #3. Three (3) weights were not documented on 6/15, 6/17 and 6/19. On 06/20/11 a weight of 340 was documented. On 06/22/11 a bed scale weight was documented at 349 (a 9 pound weight gain). Nursing staff re-weight Patient #3 per the hospital policy in weight fluctuations of 5 pounds or more.

A Hoyer scale weight was documented for Patient #3 at 372 (32 pound weight difference).
Patient #3s medical record contained no documentation that nursing staff had notifying the primary care physician of or the dietician for consult for Patient #3 weight gain. No documentation that maintenance had been notified to conduct a test of the scales used on Patient #3.

The IDT Plan of Care from admission for Patient #3s was to increase functional mobility.

Nursing documentation showed for 9 of 11 days Patient #3 had not been gotten out of bed.

On 06/22/11 at 9:00 a.m. an interview with Patient #3 was conducted in room 2075A (Patient #3s room).

Patient #3 was still in bed at 9:00 a.m. and when Surveyor #22198 left the nursing unit at 10:00 a.m. during an interview Patient #3 confirmed the nursing staff had not gotten #3 out of bed for several days however noted the need of a Hoyer lift to get out of bed, and that the hospital was short staffed today (6/22).

Patient #3s medical record failed to show Patient #3 on a bowel program and staff only offered Patient #3 a bed pan. Patient #3 told Surveyor #22198 that #3 was not aware of other options for toileting. Surveyor #22198 mentioned a bedside commode; Patient #3 told Surveyor staff had never offered the option.

On 06/23/11 at 12:00 p.m.during a telephone interview with Medical Director E confirmed he was unaware the facility did not have a bowel program.

On 06/23/11 at 10:00 a.m. during an interview RN H confirmed to Surveyors #22198 and #29963, that Patients #2 and #3 were being placed on a bed pan rather than gotten up to have a bowel movement. RN H acknowledged Patient #2 and #3 were not on any bowel program and neither patient had restrictions from placing them on a commode.

The above findings were reviewed with CNO D on 06/23/11 at

On 06/24/11 at 11:30 a.m. Surveyor #22198 reviewed Patient #5s medical record.

Patient #5 was admitted on 06/06/11 post surgical Abdominal Aneurysm repair.

Physician orders for weight every other day, Patient #5 was on tube feedings.

3 of 12 weights were not documented for Patient #5. On 6/6/11 weight was 129.6, on 6/10/11 weight was 140.8 a 7.7 % weight gain (10.9 pounds). No documentation indicated a re-weight was done per the hospital policy. No documentation of dietary or physician notification. Patient #5s weights continued to increase on 6/17 a weight of 150.4 and on 06/23/11 a weight of 153.8. The nursing staff failed to follow hospital P&P for weight gains of greater or equal to 5 pounds, and did not documentation interventions to ensure the physician and dietary were notified.

On 06/17/11 Patient #5s Nasal Gastric feeding tube (for tube feedings) was unintentionally pulled out, however physician ' s notes failed to reflect this until 3 days after the occurrence (6/20/11).

Patient #5 findings were confirmed with RN I on 06/24/11 at 11:55 a.m.

Director of QA C stated that this was a tool and not part of the permanent record. Surveyor asked him how they document that MD order for turning every 2 hours is being completed and Director of QA C stated they have no documentation.

Confirmed with CNO D and Director of QA C, on 6/24/2011 at 11:45 a.m., that a total of 9 out of 10 (#1, 2, 3, 5, 6, 7, 8, 9 and 10) open and closed medical records; failed to follow established policies written by hospital for care planning, specifically addressing weights and activity of patients

Based on review of employee files, patient record reviews and staff interviews, nursing service failed to clearly define specialized qualifications and competencies for 23 of 23 (F, G, H, I, Q, R, S, T, U, V, W, X, Y, Z, AA, BB, CC, DD, EE, FF, GG, LL, and MM) Registered Nurses (RNs) and 5 of 5 (Emergency Medical Technicians-Paramedics (EMT-P) (J, HH, II, JJ and KK).

Findings include:

On 06/22/2011 from 11:50 p.m. to 3:10 p.m. employee Registered Nurses (RN) files were reviewed by Surveyor # 22198.

Identified were 4 of 4 (F, G, H, I) RNs were documented as observed competent to perform suctioning for a patient with a tracheotomy and to respond to ventilator alarms. However, no training or education was documented for these specialized skills or ventilator certification.

2 of 4 (G and I) were documented as observed competent to perform peritoneal dialysis set up and monitoring.

1 of 4 (F) was documented as "n/a" to respond to behavioral emergency situations.

On 06/23/2011 at 8:30 a.m. RN F during a telephone interview confirmed to Surveyors #22198 and #29963, that the hospital did not provide F with education or training to perform ventilator care and tracheotomy suctioning in a safe and effective manner.

F told Surveyors that F was not qualified to perform suctioning. RN F could not explain why RN H signed Fs competency on 01/07/11 that was marked as " observed " competent to perform tracheotomy suctioning and ventilator care.

On 06/23/2011 at 9:00 a.m. RN G during a telephone interview confirmed to Surveyors #22198 and #29963, that the hospital did not provide G with education or training to perform ventilator care and tracheotomy suctioning in a safe and effective manner.

RN G told Surveyors that G was not qualified to perform suctioning. RN G could not explain why RN H signed Gs competency on 01/19/11 that was marked as " observed " competent to perform tracheotomy suctioning and ventilator care and to perform peritoneal dialysis set up and monitoring.

RN G told Surveyors the hospital does not accept peritoneal dialysis patients because there is no one in the nursing services qualified to perform peritoneal dialysis.

On 06/23/11 at 3:30 Surveyor #29963 reviewed the complaint file information from a complaint filed on behalf of Patient #1 with Director of Quality Assurance (QA) C and Chief Nursing Officer (CNO) D. Patient #1 had a tracheotomy and complaint file documentation confirmed RN G had suction Patient #1 on 05/16/11.

On 06/23/2011 at 9:25 a.m. RN I during a telephone interview confirmed to Surveyors #22198 and #29963, that the hospital did not provide " I " with education or training to perform ventilator care and tracheotomy suctioning in a safe and effective manner.

RN I told Surveyors that " I " was not ventilator certified, but felt qualified to perform tracheotomy suction and ventilator care based on other work experience not at provided by this hospital. RN I confirmed " I " had no formal documented training or education.

RN I told Surveyors " I " could not explain why " I " was signed off as " observed " competent by another RN (H) on 03/22/11 to perform tracheotomy suctioning and ventilator care and to perform peritoneal dialysis set up and monitoring when RN H had no knowledge, education or training to perform these tasks.

RN I told Surveyors the hospital does not accept peritoneal dialysis patients because there is no one in the nursing services qualified to perform peritoneal dialysis and the hospital contract hemodialysis nurses to care for hemodialysis patients in the hospital.

On 06/23/2011 at 10:00 a.m. Surveyors #22198 and #29963 conducted and interview and employee file review with RN H.

RN H told Surveyors that the hospital did not provide any formal education, training to ensure RN's provided ventilator care and tracheotomy suctioning in a safe and effective manner. RN H confirmed she is not a certified ventilator nurse.

RN H confirmed to Surveyors, H is not qualified to determine another nurse ' s skills or competencies when H herself is not qualified to perform those specific skills.

RN H confirmed to Surveyors, that she (H) had signed off on 3 of the 4 (F, G and I) as " observed " competent to perform ventilator care, suctioning and 2 of 4 (G and I) for peritoneal dialysis.

RN H confirmed no education or training documentation existed in RN Hs employee file. RN H confirmed the training was not formal and took an hour or two and was done by a contracted RT (PP) staff not employee by the hospital. (This was confirmed in an interview on 06/22/11 at 3:45 with Surveyor #22198 and CNO D)

On 06/24/11 at 8:05 a.m. during an interview Lead RT K confirmed to Surveyor #22198, that the RT department does not have a ventilator training program.

Lead RT K told Surveyor that contracted RT PP was not permitted to train hospital staff for ventilator care and that it was not a part of her job description of qualifications for the job.

Lead RT told Surveyor #22198, that he has allowed RNs to perform suction because he was not aware that RNs were not trained to perform suctioning in nursing school.

Lead RT confirmed the nursing service does not a documented process to specify which staff are qualified and competent to perform tasks.

On 06/23/2011 at 10:00 a.m. surveyor #29963 and Surveyor # 22198 interviewed RN H. RN H confirmed that RN G provided tracheotomy suction care to Patient # 1 on 04/24/2011.

On 06/24/2011 at 9:25 a.m. Surveyor # 29963 record review confirmed RN S provided tracheotomy suction care to Patient # 10 on 06/24/2011 at 0000 (Midnight).

On 06/22/2011 at 3:45 p.m. during a review of conflicting findings for the 4 of 4 RN employee files and interview, CNO D confirmed with Surveyors that 23/23 (F, G, H, I, Q, R, S, T, U, V, W, X, Y, Z, AA, BB, CC, DD, EE, FF, GG, LL, and MM) RNs were not qualified to perform tracheotomy suctioning and the RNs are not qualified to perform peritoneal dialysis.

CNO D told Surveyor that the RNs are not allowed to perform ventilator suctioning in the hospital.

On 06/22/2011 at 3:45 p.m. during an interview CNO D confirmed to Surveyor #22198, that 23/23 (F, G, H, I, Q, R, S, T, U, V, W, X, Y, Z, AA, BB, CC, DD, EE, FF, GG, LL, and MM) nurses had the same conflicting documentation on their hospital specific competencies in their employee files.

CNO D confirmed to Surveyors, that D had identified the failure in training, education and skills competencies when D started in March 2011. However, CNO D failed to stop nurses from performing tasks RNs were not qualified by training, education and competencies to perform.

" N 6.03 Standards of practice for registered nurses. "
" N 6.03(2)(b) Accept only those delegated medical acts for which the R.N. is competent to perform based on his or her nursing education, training or experience; "
Retrieved from "STANDARDS OF PRACTICE FOR REGISTERED NURSES AND LICENSED PRACTICAL NURSES " at:

CNO D confirmed to Surveyor #22198, that currently the nursing service had no way to disseminate which nursing staff were competent and qualified to perform specific nursing tasks, so Charge Nurses and RNs that are responsible for assignments and delegation of nursing duties based on training, education, competency and qualifications could delegate nursing duties per .

" N 6.03 Standards of practice for registered nurses."
" N 6.03(1)(c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.'s or less skilled assistants. "
Retrieve from STANDARDS OF PRACTICE FOR REGISTERED NURSES AND LICENSED PRACTICAL NURSES at:

On 06/22/2011 from 11:50 p.m. to 3:10 p.m. 1 of 5 Emergency Medical Technician-Paramedics (EMT-P) (J) employee files were reviewed by Surveyor # 22198.

EMT-P Js employee file confirmed that EMT-Ps were working under their own licensure in the hospital performing first responder duties and codes.

On 06/23/11 during telephone interviews conducted at 8:30 a.m. with RN F, 9:00 a.m. with RN G, 9:25 a.m. with RN I and a face to face interview with RN H at 10:00 a.m. all nurses thought EMT-Ps worked in the hospital under their own State EMT licensure.

RNs F, G, H and I all confirmed that EMT-Ps performed direct patient care described as turning and repositioning, assistance with transfers, cleaning patients up and medication pass that included all medications and tube feedings.

RNs F, G, H and I were not aware of any restrictions on EMT-Ps duties.

On 06/23/11 at 11:35 during a telephone interview EMT-P J confirmed the duties described by RN F, G H and I. EMT-P J also trained new EMTs employed by the hospital.

EMT-P told Surveyors #22198 and #29963 that the hospital employed EMTs will do anything that the nursing staff asks them to do that included direct patient care duties.

EMT-P J was not aware that the EMT licensure only covered EMT-Ps for duties performed in emergency services in a pre-hospital arena.

On 06/23/11 12:00 p.m. in a telephone interview with Medical Director E confirmed to Surveyors #22198 and #29963, that the EMTs were not covered under medical staff supervision or oversight. Medical Director E told Surveyors, E, thought the EMTs were covered under EMT State licensure.

On 06/23/11 at 12:30 p.m. during a telephone interview the State of Wisconsin Director of Emergency Medical Services (EMS) services NN. NN confirmed to Surveyor #22198, EMTs are licensed to work in a pre-hospital arena that is all their EMT licensure will cover, no matter what level of EMT they are.

State of Wisconsin Director of EMS services NN told Surveyor #22198, that if a hospital chooses to employee EMTs, the hospital is responsible for the oversight of the EMTs work, and that the EMT license is not transferable, and that EMT-Ps are not trained to give all medication, and are not trained to give tube feedings.

During an interview on 06/23/11 at 4: 15 p.m. Director of QA C confirmed to Surveyor #22198 and Surveyor #29963 the facility was not aware that the EMTs license would not cover them while working inside a hospital, and that currently EMTs are working under the RNs on duty with direct oversight from the CNO D (also defined in the job description).

On 06/23/11 at 12:15 Surveyor #22198 called the Office of Caregiver Quality (OCQ) to determine what defines a caregiver under the law and are EMTs included in the caregiver law as nurse aids if they are providing direct patient cares.

On 06/23/11 at 12:15 Surveyor #22198 and OCQ OO discussed the above findings.

OCQ OO confirmed to Surveyor #22198 that an EMT doing direct patient care as described by EMT-P J and CNO D is considered "direct patient care", that EMTs working in this capacity should have nurse aid training and be placed on the registry.
OCQ OO told Surveyor #22198, that EMTs although skilled in the work they perform for EMS services, does not receive training like; restorative care or dementia training.

On 06/22/11 at 3:45 p.m. CNO D and Director of QA C confirmed that the hospital had not provided any formal training or education to the EMTs to ensure care was provided based on hospital regulation requirement or hospital P&P.

On 06/22/11 at 3:45 p.m. CNO D and Director of QA C confirmed that the competency assessment was based off of the EMT licensure skill, and not the in-patient hospital setting.

On 06/22/11 at 3:45 p.m. CNO D and Director of QA C confirmed that the hospital had not provided any additional hospital based training and education to perform medication pass, a duty assigned to licensed nursing personnel, and that currently RNs are assigning EMT-Ps with duties the hospital has not trained EMTs to perform or competency tested to ensure they are qualified.

On 06/23/11 at 1:19 p.m. Director of Human Resources (HR) B confirmed to Surveyor #22198, that 5 of 5 EMT-Ps (J, HH, II, JJ and KK) employee files failed to have documented education and training to ensure competency based qualifications for all hospital based tasks EMTs were performing. Also present was Director of QA C.

Director of HR B confirmed to Surveyor that the EMTs who were currently performing nurse aid duties and direct patient care tasks were not on the caregiver registry.

On 06/23/11 at 3:45 a review of all findings was conducted by Surveyors #22198 and #29963 and confirmed by Director of QA C and CNO D.