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Based on document review and interview the facility failed to ensure patients received care in a safe setting. The facility practice of staffing nurses did not take into consideration the complexity of the patient's health needs. The facility allowed Paramedics to practice in the facility without medical supervision.

Refer to tag A0144

Based on document review and interview the facility failed to:

A. follow the established administrative authority provided to the director of nurses. The Administrator of the facility developed and implemented a "Nurse Staffing Grid". The Administrator was not a registered nurse and was not qualified to determine the types and numbers of nursing personnel and staff necessary to provide nursing care to the patients seeking care in the facility. This staffing grid did not comply with the approved Nurse Staffing Plan.
Refer to A0386

B. provide a Registered Nurses to be immediately available for bedside care of patients if needed.
Refer to A0392

C. provide evidence 5 of 5 Licensed Vocation al Nurses (LVN) provided nursing care within their scope of practice for high acuity ventilator dependent patients.

Refer to tag A0397

D. The facility was allowing Paramedics (unlicensed staff) to practice in the facility without medical supervision.
Refer to tag A0405

It was determined that these deficient practices of not following policy and procedures created an Immediate Jeopardy situation, resulting in the likelihood of harm, serious injury, and subsequent death to patients. The patients' level of nursing skill needed or the level of the skilled nurses was not being considered when staffing.

Based on document review and interviews the facility failed to:
A. staff nursing personnel in a safe manner and with consideration of the patients' healthcare needs.
A review of the document titled "Nurse Staffing Grid" revealed the facility does not distinguish between an RN and LVN. The facility staffs nurses by the number of patients admitted, dictating the number of nurses needed.
Upon arrival to the Medical Floor Staff #3 was observed at the nurses' desk talking with staff. No RN was immediately available on the High Observation Floor.
An interview was conducted with staff #3 on 1/8/15 standing at the nurses' desk located on the Medical Floor. Staff #3 revealed the staffing practice is to staff two RNs and the other nursing staff would be LVNs. Staff #3 revealed one RN was responsible for the High Observation floor and the other RN was responsible for the medical floor. The interview revealed staff #3 was the supervising RN on the High Observation Floor.
An interview with staff #4 revealed the staffing practice is to staff two RNs and the other nursing staff would be LVNs. Staff #4 was the only RN scheduled on the Medical Floor and was the primary nurse of four patients. The interview confirmed staff #4 was not the supervising RN on the Medical Unit .

B. Provide Paramedics with medical supervision.
A review of the Texas Board of Nurse web site revealed:
"The rules governing EMTs and Paramedics are located in Title 25, Texas Administrative Code, Section 157.2. This rule limits the scope of practice of EMTs/Paramedics to performing duties in the "pre-hospital and inter-facility transport" settings. Therefore, whether certified or licensed, the BON delegation rules view EMTs, Paramedics, or other similarly trained staff as "unlicensed assistive personnel" (UAPs) when working in acute care settings, such as the ED.

Each RN decides on a case-by-case basis what nursing tasks may be delegated to unlicensed personnel in accordance with Rule 224 (relating to RN delegation in acute care settings or for patients with acute conditions). It should be noted that position descriptions developed by employing institutions can neither mandate RN delegation, nor force RN delegation by facility policy or physician order.

The BON's delegation Rule 224 is not prescriptive to specific procedures or tasks that may or may not be delegated. Rule 224 permits a RN to delegate starting a peripheral IV saline lock to an unlicensed person providing all of the delegation criteria are met. The applicable section of Rule 224 in delegating this task is 224.8(b), Discretionary Delegation Tasks, under (2)(A), Sterile Procedures. Section 224.8(c)(5) does prohibit delegation of administration of IV fluids, so an unlicensed tech in the ED could not connect and administer a bag of IV fluid under RN delegation.

Other laws outside of the BON's jurisdiction may prohibit performance of certain tasks by unlicensed personnel, even if a physician is willing to delegate a task. Under physician delegation, the physician must willingly make the decision and delegate the task(s) and such delegation must be permitted by hospital/facility policy. BON staff cannot speak as experts on the Texas Medical Board's (TMB) rules; however, Rule 193 of the TMB Rules addresses "physician delegation." You may wish to contact the TMB at (512) 305-7010, or check their web site at Texas Medical Board for more information on this law.

The delegation rules also address the RN who may be supervising an unlicensed person to whom the physician has delegated tasks. The RN always has a responsibility to protect client safety [217.11(1)(B)], so the RN has a duty to intervene if he/she sees something being done incorrectly by the unlicensed person, and to notify the delegating practitioner of the incident. For additional information on EMTs and Paramedics in the pre-hospital and interfacility transport setting, check the Texas Department of State Health Services web site at Home - DSHS EMS & Trauma Systems, or, to access applicable laws, see Texas Legislature Online at TLO. "

A review of the Title 25, Texas Administrative Code, Section 157.2. revealed
(20) Department - The Texas Department of Health.
(35) Emergency medical technician-paramedic (EMT-P) - An individual who is certified by the department as minimally proficient to provide emergency pre-hospital or inter-facility care by providing advanced life support that includes initiation and maintenance under medical supervision of certain procedures, including intravenous therapy, endotracheal or esophageal intubation or both, electrical cardiac defibrillation or cardioversion, and drug therapy.
(37) Emergency pre-hospital care - Care provided to the sick and injured before or during transportation to a medical facility, including any necessary stabilization of the sick or injured in connection with that transportation.
(43) Inter-facility care - Care provided while transporting a patient between medical facilities.
(51) Medical supervision - Direction given to emergency medical services personnel by a licensed physician under the terms of the Medical Practice Act, (Texas Civil Statutes, Chapter 6, Article 4495b) and rules promulgated by the Texas State Board of Medical Examiners pursuant to the terms of the Medical Practice Act.

A review of the Texas Board of Nursing Rule 224.8 Delegation of Tasks revealed:

"(2) the following are nursing tasks that are not usually within the scope of sound professional nursing judgment to delegate and may be delegated only in accordance with, §224.6 of this title and paragraph (1) of this subsection. These types of tasks include:
(A) sterile procedures--those procedures involving a wound or an anatomical site which could potentially become infected;
(B) non-sterile procedures, such as dressing or cleansing penetrating wounds and deep burns;
(C) invasive procedures--inserting tubes in a body cavity or instilling or inserting substances into an indwelling tube; and
(D) care of broken skin other than minor abrasions or cuts generally classified as requiring only first aid treatment.

(c) Nursing Tasks Prohibited from Delegation By way of example, and not in limitation, the following are nursing tasks that are not within the scope of sound professional nursing judgment to delegate:
(1) physical, psychological, and social assessment which requires professional nursing judgment, intervention, referral, or follow-up;
(2) formulation of the nursing care plan and evaluation of the client's response to the care rendered;
(3) specific tasks involved in the implementation of the care plan which require professional nursing judgment or intervention;
(4) the responsibility and accountability for client health teaching and health counseling which promotes client education and involves the client's significant others in accomplishing health goals; and
(5) administration of medications, including intravenous fluids, except by medication aides as permitted under §224.9 of this title (relating to The Medication Aide Permit Holder)

A review of the document titled
PARAMEDIC/MONITOR TECH. DEPARTMENT:
LTACH, SUPERVISOR: Reports to the CNO under the direction of Medical Director.
II. POSITION SUMMARY:
Under the general direction of the Nursing Supervisor and the CNO, the paramedic works as a member of the team demonstrating knowledge and applying current theory and principles of care in the performance of the following functions appropriate to the age of the patient in the delivery of quality care and services; emergency and routine care of the patient, maintains a safe and clean environment, participates in quality improvement, consistently contributes to the operations and communication, behaves in a manner consistent with the mission and objectives of Harbor Hospital of Southeast Texas and performs other duties as requested.
A. Coordinates patient care services provided on the LTACH Unit on designated shifts.
B. Functions as a resource person for staff members and assists in necessary education of individual members of nursing staff with a focus on promoting clinical competence and other duties as assigned.
C. Ensures adherence to standards on the unit based on Administrative Operational Standards, Human Resource Standards, Department of Nursing Standards, in collaboration with the Director in unusual situations.

COMPETENCIES
B. TECHNICAL COMPETENCIES.
1. Interprets and implements operational standards as applicable to the LTACH Unit.
2. Develops and ensures implementation of operational standards within the unit which promote the maintenance of Patient rights and safety including, but not limited to:
a. Assesses the nature and extent of the medical emergency and prioritize the interventions to be followed and the need for assistance
b. Restores and stabilizes heart rhythm on pulseless, non-breathing Patient.
c. Performs insertion of LMA if unable to establish airway via endotracheal or nasotracheal intubation.
d. Performs endotracheal or nasotracheal intubation and cricothyrotomy to open airways and ventilate the Patient in the event of a cardiac and/or respiratory arrest.
d. Administer IV/intraosseous emergency drugs in an emergency i.e.: Code blue/CRT.
e. Assist in obtaining and recording vital signs during an emergency when possible
f. Assist in any emergencies that are needed but not limited to in-hospital setting je: ER room, Patient entering the facilities with emergencies needing to be stabilized....
h. May assist in peripheral, external jugular IV insertion and blood draws.
5. Demonstrates sound knowledge base in paramedic theory and its clinical applications in the LTACH care setting.
6. Demonstrates sound knowledge of paramedic techniques and procedures utilized in the areas of responsibility.
7. Demonstrates knowledge and skills necessary to provide care to patients and families served in relation to growth and development over their life span and identify their requirements relative to their age-specific needs.
a. Adapts patient care standards to the needs of the adult and older adult in planning and providing care for patients admitted to the LTACH Unit.
b. Applies knowledge of physiological, psychological, and sociological changes in the older adult in planning and providing care.
8. Demonstrates thorough knowledge of the use of emergency equipment and its Operation to provide direct care in a safe manner.

A review of the document titled Medical Staff Rules and Regulations, Medical Staff Bylaws, and Bylaws of the Governing Board revealed no guidance or privileges for Paramedics. These documents provided no evidence the Paramedic was under the direction of Medical Director

Interviews with staff #1, 3 and 4 confirmed the Paramedics were using intubating patients and assisting with code blues (cardiac or respiratory arrest) in the facility.

Based on document review and interview the facility failed to follow the established administrative authority provided for the director of nurses. The Administrator of the facility developed and implemented a "Nurse Staffing Grid". The Administrator was not a registered nurse and was not qualified to determine the types and numbers of nursing personnel and staff necessary to provide nursing care to the patients seeking care in the facility. This staffing grid did not comply with the approved Nurse Staffing Plan.
It was determined that these deficient practices of not following policy and procedures created an Immediate Jeopardy situation, resulting in the likelihood of harm, serious injury, and subsequent death to patients. The patients ' level of nursing skill needed or the level of the skilled nurses was not being considered when staffing.

A review of the document titled Nurse Staffing Plan revealed:
1. The staffing plan for patient care areas shall provide an effective balance between the needs of patients and appropriate levels and skill mix of nursing staff. There shall be adequate numbers of registered nurses, licensed vocational nurses and other personnel to provide nursing care to all patients as needed.
2. There shall be supervisory and nursing personnel for each nursing department to provide the immediate availability of a RN for bedside care of any patient, as needed.
3. An RN shall supervise and evaluate the nursing care for each patient and assign the nursing care to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available.
4. The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse's obligation to provide optimum patient care
5. Staffing shall be sufficient to provide prompt recognition of any unforeseen change in the patient's condition and to facilitate appropriate nursing/medical staff intervention.
6. The registered nurse shall be responsible for administering patient care, which cannot be delegated to a licensed vocational nurse
7 The registered nurse shall assume responsibility for the designated patient care area to which she or he is assigned as defined by the Charge Nurse .....
12. The hospital requires orientation of nurses and other personnel, including contract staff, who provide nursing care to units they are assigned on either a temporary or permanent basis. Nursing assignments will be congruent with documented competency.
A review of the document titled "Nurse Staffing Grid" revealed the facility does not distinguish between an RN and LVN. The facility staffs nurses by the number of patients admitted and this dictates the number of nurses needed.
An interview was conducted with staff #3 on 1/8/15 standing at the nurses' desk located on the Medical Floor. Staff #3 revealed the staffing practice was to staff two RNs and the other nursing staff would be LVNs. Staff #3 revealed one RN was responsible for the High Observation floor and the other RN was responsible for the medical floor. The interview revealed staff #3 was the supervising RN on the High Observation Floor.
An interview with staff #4 revealed the staffing practice was to staff two RNs and the other nursing staff would be LVNs.
An interview on 1/7/15 staff #1 revealed a nurse staffing grid was being used for the purpose of staffing. Staff #1 developed and implemented the nurse staffing grid. Staff #1 was not a registered nurse and was qualified to determine the types and numbers of nursing personnel and staff necessary to provide nursing care to the patients seeking care in the facility.

Based on document review and interview the facility failed to provide a Registered Nurse to be immediately available for bedside care of patients if needed.
It was determined that these deficient practices of not following policy and procedures created an Immediate Jeopardy situation, resulting in the likelihood of harm, serious injury, and subsequent death to patients. The patients' level of nursing skill needed or the level of the skilled nurses was not being considered when staffing.

A review of the document titled "Nurse Staffing Grid" revealed the facility does not distinguish between an RN and LVN. The facility staffs nurses by the number of patients admitted, dictating the number of nurses needed.
Upon arrival to the Medical Floor, Staff #3 was observed at the nurses' desk talking with staff. No RN was immediately available on the High Observation Floor.
An interview was conducted with staff #3 on 1/8/15 standing at the nurses' desk located on the Medical Floor. Staff #3 revealed the staffing practice was to staff two RNs and the other nursing staff would be LVNs. Staff #3 revealed one RN was responsible for the High Observation floor and the other RN was responsible for the medical floor. The interview revealed staff #3 was the supervising RN on the High Observation Floor.
An interview with staff #4 revealed the staffing practice was to staff two RNs and the other nursing staff would be LVNs. Staff #4 was the only RN scheduled on the Medical Floor and was the primary nurse of four patients. The interview confirmed staff #4 was not the supervising Medical Unit Nurse. When asked, could you be immediately avaliable at the beside of any patient on the medical unit needing an RN assessment the reply was no.

Based on interview and document review the facility failed to provide evidence 5 of 5 Licensed Vocational Nurses (LVN) provided nursing care within their scope of practice for high acuity ventilator depended patients.

On 1/7/2015 at 3:30 p.m. in the conference room, an interview with the Administrator confirmed LVNs were assigned as primary nurses in the High Observation (High-Obs) unit. The Administrator confirmed there was 1 Registered Nurse (RN) who also worked in High Observation unit. Review of the nursing assignments confirmed the single RN had three (3) ventilator dependeent patients assigned to her for the shift. Further review revealed there was also one RN charge nurse who provided supervision for the High-Obs unit and the medical unit on the same floor of the hospital.

On 1/7/2015 at 1:00 in the conference room the educational records for 7 nursing staff (2 Registered Nurses and 5 Licensed Vocational Nurses) were reviewed and revealed the following:
1. All seven (7) nurses received the same training from the facility identified as "Clinical Competency and Skills Day".
2. The employee record for each of the 7 nurses contained a single data sheet, containing the following 11 listed competencies:
Wound care,
IV's, Blood Products, High alert medications,
Restraints,
Ventilator and Respiratory Care,
Patient medication safety/Pharmacy,
Patient Safety Devices,
Nutritional,
Documentation,
Employee and Patient Vaccines,
Infection Prevention,
Environment of Care/Safety
Human Resources Reminders/Policy Updates

3. A mark appeared on the row after skill.
4. There was no legend for the mark in the column (explaining who provided the training or how the training was provided)
5. There was no curriculum attached to the training.
6. There was no documentation of demonstrated competency by the employee.
7. There was no discrimination between the skill expected from an RN and the skills expected from an LVN.

On 1/8/2015 at 11:00 in the office of the Director of Respiratory Services, an interview with the Respiratory Therapy Services Director revealed she gave the skills day training for "Restraints, Ventilator and Respiratory Care". Further interview revealed nursing staff were instructed on how to "trouble shoot" the ventilators. When asked to clarify the Director revealed she taught the nurses to silence the alarm on the ventilator long enough to evaluate the patient and attempt to determine what the problem was. She went on to say, only a Respiratory Therapist or the Physician was permitted to change a patient's ventilator setting. The nurse would evaluate and contact the Respiratory Therapy staff. The Director revealed she was very protective of her ventilator patients and had requested more than one Registered Nurse be removed from the unit because she felt their skills were not where they should be to safely care for a ventilator patient. This statement indicated the Licensed Vocational Nurse could be in the unit with no immediate RN supervision.
Review of the State Board of Nursing scope of Practice for a Licensed Vocation Nurse revealed the following:
Nursing Practice Act - Chapter 301
Subchapter A. General Provisions
Sec. 301.001. Short Title.
This chapter may be cited as the Nursing Practice Act.
Sec. 301.002. Definitions.
5) "Vocational nursing" means a directed scope of nursing practice, including the performance of an act that requires specialized judgment and skill, the proper performance of which is based on knowledge and application of the principles of biological, physical, and social science as acquired by a completed course in an approved school of vocational nursing. The term does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures. Vocational nursing involves:
(A) collecting data and performing focused nursing assessments of the health status of an individual;
(B) participating in the planning of the nursing care needs of an individual;
(C) participating in the development and modification of the nursing care plan;
(D) participating in health teaching and counseling to promote, attain, and maintain the optimum health level of an individual;
(E) assisting in the evaluation of an individual's response to a nursing intervention and the identification of an individual's needs; and
(F) engaging in other acts that require education and training, as prescribed by board rules and policies, commensurate with the nurse's experience, continuing education, and demonstrated competency.
The facility could not provide documentation of special competencies, or demonstrated skill checked by a Registered Nurse or Certified Respiratory Therapist for the Licensed Vocational Nurses who were assigned to care for the Ventilator dependent patients in the "High Observation unit"
The Texas Nursing Practice Act (NPA) defines the legal scope of practice for professional registered nurses (RNs). " Professional nursing " means the performance of an act that requires substantial specialized judgment and skill, the proper performance of which is based on knowledge and application of the principles of biological, physical, and social science as acquired by a completed course in an approved school of professional nursing. The term does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures. Professional nursing involves:
A. the observation, assessment, intervention, evaluation, rehabilitation, care and counsel, or health teachings of a person who is ill, injured, infirm, or experiencing a change in normal health processes;
B. the maintenance of health or prevention of illness;
C. the administration of a medication or treatment as ordered by a physician, podiatrist, or dentist;
D. the supervision or teaching of nursing;
E. the administration, supervision, and evaluation of nursing practices, policies, and procedures;
F. the requesting, receiving, signing for, and distribution of prescription drug samples to patients at practices at which an advanced practice registered nurse is authorized to sign prescription drug orders as provided by Subchapter B, Chapter 157;
G. the performance of an act delegated by a physician under Section 157.0512, 157.054, 157.058, or 157.059; and
H. the development of the nursing care plan.
The RN takes responsibility and accepts accountability for practicing within the legal scope of practice and is prepared to work in all health care settings, and may engage in independent nursing practice without supervision by another health care provider. The RN, with a focus on patient safety, is required to function within the parameters of the legal scope of practice and in accordance with the federal, state, and local laws; rules and regulations; and policies, procedures and guidelines of the employing health care institution or practice setting. The RN is responsible for providing safe, compassionate, and comprehensive nursing care to patients and their families with complex healthcare needs.
The facility assigned LVNs, who by definition do not have the education to perform complex nursing skills, and by scope of practice guidelines require RN/Advance Practice RN/Physician/Physician Assistant supervision when providing nursing care, to provide primary care to ventilator dependent patient in an unsupervised nursing care setting.

Based on document review and interview the facility failed to supervise Paramedics. The facility was allowing Paramedics (unlicensed staff) to practice in the facility without medical supervision.
A review of the Texas Board of Nurse web site revealed: "The rules governing EMTs and Paramedics are located in Title 25, Texas Administrative Code, Section 157.2. This rule limits the scope of practice of EMTs/Paramedics to performing duties in the "pre-hospital and inter-facility transport" settings. Therefore, whether certified or licensed, the BON delegation rules view EMTs, Paramedics, or other similarly trained staff as "unlicensed assistive personnel" (UAPs) when working in acute care settings, such as the ED.

Each RN decides on a case-by-case basis what nursing tasks may be delegated to unlicensed personnel in accordance with Rule 224 (relating to RN delegation in acute care settings or for patients with acute conditions). It should be noted that position descriptions developed by employing institutions can neither mandate RN delegation, nor force RN delegation by facility policy or physician order.

The BON's delegation Rule 224 is not prescriptive to specific procedures or tasks that may or may not be delegated. Rule 224 permits a RN to delegate starting a peripheral IV saline lock to an unlicensed person providing all of the delegation criteria are met. The applicable section of Rule 224 in delegating this task is 224.8(b), Discretionary Delegation Tasks, under (2)(A), Sterile Procedures. Section 224.8(c)(5) does prohibit delegation of administration of IV fluids, so an unlicensed tech in the ED could not connect and administer a bag of IV fluid under RN delegation.

Other laws outside of the BON's jurisdiction may prohibit performance of certain tasks by unlicensed personnel, even if a physician is willing to delegate a task. Under physician delegation, the physician must willingly make the decision and delegate the task(s) and such delegation must be permitted by hospital/facility policy. BON staff cannot speak as experts on the Texas Medical Board's (TMB) rules; however, Rule 193 of the TMB Rules addresses "physician delegation." You may wish to contact the TMB at (512) 305-7010, or check their web site at Texas Medical Board for more information on this law.

The delegation rules also address the RN who may be supervising an unlicensed person to whom the physician has delegated tasks. The RN always has a responsibility to protect client safety [217.11(1)(B)], so the RN has a duty to intervene if he/she sees something being done incorrectly by the unlicensed person, and to notify the delegating practitioner of the incident. For additional information on EMTs and Paramedics in the pre-hospital and interfacility transport setting... check the Texas Department of State Health Services web site at Home - DSHS EMS & Trauma Systems, or, to access applicable laws, see Texas Legislature Online at TLO."

A review of the Title 25, Texas Administrative Code, Section 157.2. revealed
(20) Department - The Texas Department of Health.
(35) Emergency medical technician-paramedic (EMT-P) - An individual who is certified by the department as minimally proficient to provide emergency prehospital or interfacility care by providing advanced life support that includes initiation and maintenance under medical supervision of certain procedures, including intravenous therapy, endotracheal or esophageal intubation or both, electrical cardiac defibrillation or cardioversion, and drug therapy.
(37) Emergency prehospital care - Care provided to the sick and injured before or during transportation to a medical facility, including any necessary stabilization of the sick or injured in connection with that transportation.
(43) Interfacility care - Care provided while transporting a patient between medical facilities.
(51) Medical supervision - Direction given to emergency medical services personnel by a licensed physician under the terms of the Medical Practice Act, (Texas Civil Statutes, Chapter 6, Article 4495b) and rules promulgated by the Texas State Board of Medical Examiners pursuant to the terms of the Medical Practice Act.

A review of the Texas Board of Nursing Rule 224.8 Delegation of Tasks revealed:

(2) the following are nursing tasks that are not usually within the scope of sound professional nursing judgment to delegate and may be delegated only in accordance with, §224.6 of this title and paragraph (1) of this subsection. These types of tasks include:
(A) sterile procedures--those procedures involving a wound or an anatomical site which could potentially become infected;
(B) non-sterile procedures, such as dressing or cleansing penetrating wounds and deep burns;
(C) invasive procedures--inserting tubes in a body cavity or instilling or inserting substances into an indwelling tube; and
(D) care of broken skin other than minor abrasions or cuts generally classified as requiring only first aid treatment.

(c) Nursing Tasks Prohibited from Delegation By way of example, and not in limitation, the following are nursing tasks that are not within the scope of sound professional nursing judgment to delegate:
(1) physical, psychological, and social assessment which requires professional nursing judgment, intervention, referral, or follow-up;
(2) formulation of the nursing care plan and evaluation of the client's response to the care rendered;
(3) specific tasks involved in the implementation of the care plan which require professional nursing judgment or intervention;
(4) the responsibility and accountability for client health teaching and health counseling which promotes client education and involves the client's significant others in accomplishing health goals; and
(5) administration of medications, including intravenous fluids, except by medication aides as permitted under §224.9 of this title (relating to The Medication Aide Permit Holder)

A review of the document titled:
PARAMEDIC/MONITOR TECH. DEPARTMENT: LTACH
SUPERVISOR: Reports to the CNO under the direction of Medical Director
II. POSITION SUMMARY:
Under the general direction of the Nursing Supervisor and the CNO, the paramedic works as a member of the team demonstrating knowledge and applying current theory and principles of care in the performance of the following functions appropriate to the age of the patient in the delivery of quality care and services; emergency and routine care of the patient, maintains a safe and clean environment, participates in quality improvement, consistently contributes to the operations and communication, behaves in a manner consistent with the mission and objectives of Harbor Hospital of Southeast Texas and performs other duties as requested.
A. Coordinates patient care services provided on the LTACH Unit on designated shifts.
B. Functions as a resource person for staff members and assists in necessary education of individual members of nursing staff with a focus on promoting clinical competence and other duties as assigned.
C. Ensures adherence to standards on the unit based on Administrative Operational Standards, Human Resource Standards, Department of Nursing Standards, in collaboration with the Director in unusual situations.

COMPETENCIES
B. TECHNICAL COMPETENCIES.
1. Interprets and implements operational standards as applicable to the LTACH Unit.
2. Develops and ensures implementation of operational standards within the unit which promote the maintenance of Patient rights and safety including, but not limited to:
a. Assesses the nature and extent of the medical emergency and prioritize the interventions to be followed and the need for assistance
b. Restores and stabilizes heart rhythm on pulseless, non-breathing Patient.
c. Performs insertion of LMA if unable to establish airway via endotracheal or nasotracheal intubation.
d. Performs endotracheal or nasotracheal intubation and cricothyrotomy to open airways and ventilate the Patient in the event of a cardiac and/or respiratory arrest.
d. Administer IV/intraosseous emergency drugs in an emergency i.e.: Code blue/CRT.
e. Assist in obtaining and recording vital signs during an emergency when possible
f. Assist in any emergencies that are needed but not limited to in-hospital setting je: ER room, Patient entering the facilities with emergencies needing to be stabilized ....
h. May assist in peripheral, external jugular IV insertion and blood draws.
5. Demonstrates sound knowledge base in paramedic theory and its clinical applications in the LTACH care setting.
6. Demonstrates sound knowledge of paramedic techniques and procedures utilized in the areas of responsibility.
7. Demonstrates knowledge and skills necessary to provide care to patients and families served in relation to growth and development over their life span and identify their requirements relative to their age-specific needs.
a. Adapts patient care standards to the needs of the adult and older adult in planning and providing care for patients admitted to the LTACH Unit.
b. Applies knowledge of physiological, psychological, and sociological changes in the older adult in planning and providing care.
8. Demonstrates thorough knowledge of the use of emergency equipment and its Operation to provide direct care in a safe manner.

A review of the document titled Medical Staff Rules and Regulations, Medical Staff Bylaws, and Bylaws of the Governing Board revealed no guidance or privileges for Paramedics. These documents provided no evidence the Paramedic was under the direction of Medical Director

Interviews with staff #1, 3 and 4 confirmed the Paramedics were intubating patients and assisting with code blues (cardiac or respiratory arrest) in the facility.