HospitalInspections.org

A) Based on record review and interview, the Governing Body, Medical Staff, and Chief Nursing Officer directed and allowed paramedics to function outside their scope of practice (Scope includes: provide Advanced Life Support in the facility and/or function as an unlicensed personnel) while providing patient care in a Healthcare Facility Setting.


TITLE 22 EXAMINING BOARDS, PART 11 TEXAS BOARD OF NURSING, CHAPTER 224 DELEGATION OF NURSING TASKS BY REGISTERED PROFESSIONAL NURSES TO UNLICENSED PERSONNEL FOR CLIENTS WITH ACUTE CONDITIONS OR IN ACUTE CARE ENVIRONMENTS...Rule §224.5, "RN Accountability for Delegated Tasks The RN nurse administrator or the RN who is responsible for nursing services in settings that utilize RN delegation in clients with acute care conditions or acute care environments shall be responsible for knowing the requirements of this rule and for taking reasonable steps to assure that registered nurse delegation is implemented and conducted in compliance with the Texas Nursing Practice Act and this chapter..."


Cross Reference to Tag A0084, A0144, and A0386;


B) Based on record review and interview, the facility failed to maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program, in that, the hospital did not have Quality Assessment and Performance Improvement Committee Meetings to document actions aimed at performance improvement, or to measure success and track performance to ensure that improvements were made and sustained for 2016 and 2017.

Cross Reference to Tag A0283

Based on record review and interview, the facility failed to maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program, in that,

the hospital did not have Quality Assessment and Performance Improvement Committee Meetings to document actions completed aimed at performance improvement, or to measure success and track performance to ensure that improvements were made and sustained for 2016 and 2017.

Cross Reference to A0283

Based on record review and interview, the hospital failed to have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care, in that,

the Chief Nursing Officer directed and allowed paramedics to function outside their scope of practice (Scope includes: provide Advanced Life Support in the facility and/or function as an unlicensed personnel) while providing patient care in a Healthcare Facility Setting.

Cross Reference A0386

Based on record review and interview, the Governing Body failed to ensure quality medical services are provided in a safe and effective manner that permits the hospital to comply with all applicable rules and standards. The Governing Body, Medical Staff and Chief Nursing Officer directed and allowed paramedics to function outside their scope of practice (Scope includes: provide Advanced Life Support in the facility and/or function as an unlicensed personnel) while providing patient care in a Healthcare Facility Setting.


Findings included:


The hospital personnel list provided on 3/08/17 included one paramedic (Personnel #28) working in surgery, 2 paramedics (Personnel # 51 and #52) working in the emergency room, and 5 paramedics (Personnel #30, #53, #54, #55 and #56) working in the Urgent Care.


Personnel (Paramedic) #23's skills checklist reflected competencies completed on 8/14/08 (with some updates in May 2016) for the operating room equipment competencies, a medication administration competency exam, Alaris IV Pump, i-Stat training test, orthopedic splinting, suturing lacerations, blood cultures, urinary catheterization, intravenous access, Nasogastric/Orogastric (NG/OG) tube insertion, blood product administration, malignant hyperthermia, restraints application, crutch training, blood transfusion administration, cervical spine immobilization, and EKG rhythm recognition.


Personnel (Paramedic) #24's skills checklist reflected competencies completed on 5/22/08 (with some updates on 3/31/16) for medication calculation test, blood transfusion test, competency for Alaris IV pump, IV catheter insertion competency, SureStep Glucometer, i-Stat, Group A Rapid Strep, Blood Sample collection competency test, assessment and cleansing of wound, application of local anesthetic, utilization of sterile technique, performing wound repair, wound care education, training with Loopes, Mik-Key G-button replacement, Central Line repairs, medication administration/calculation test, blood culture collection, suturing, lidocaine administration, restraint application/seclusion, glucometer testing, C-spine immobilization, crutch training, EKG rhythm recognition testing, suturing of lacerations competency, and EKG rhythm recognition testing.


Personnel (Paramedic) #28 skills checklist reflected competencies completed on 1/17/14 (with some updates on 8/19/16) for intravenous access on the pediatric patient, insertion of NG/OG tubes, lavage procedure, urinary catheterization, orthopedic splinting, soft tissue injury, vein illumination skills, and medication administration test.


Personnel (Paramedic) #29 skills checklist reflected competencies completed on 6/07/16 for restraint/seclusion, IV access competency checklist, blood culture collection, insertion of OG/NG tubes, lavage procedure, urinary catheterization, care of patient receiving urinary catheterization care of patient requiring orthopedic splinting,


Personnel (Paramedic) #30 skills checklist reflected competencies completed on 12/08/15 (with some updates on 12//03/16) for IV access, Alaris IV Pump module, insertion of OG/NG tube, lavage procedure, urinary catheterization, and orthopedic splinting.


Personnel (Paramedic) #31 skills checklist reflected competencies completed on 9/15/15, with some updates on 3/29/16 for the Alaris IV pump, IV access, medication dosage calculations, insertion of nasogastric tubes, restraint use, glucose testing, clean catch urine collection, insertion of urinary catheterization, and orthopedic splinting.


Personnel (Paramedic) #32 skills checklist reflected competencies completed on 11/02/11 (with some updates on 4/19/16) for intravenous medication administration, insertion of oral and nasogastric tubes, urinary catheterization, soft tissue injury, orthopedic splinting, crutch training, application of local anesthetic, performing wound repair, blood culture collection procedure, medication administration test, and blood culture collection.


Personnel (Paramedic) #33 skills checklist reflected competencies completed on 10/07/11 (with some updates on 3/21/16) for intravenous Therapy of the pediatric patient, insertion of OG(oral-gastric)/NG (naso-gastric) tubes, urinary catheterization, collection of urinary specimen, providing care to pediatric patients with soft tissue injuries, providing care to the pediatric patient requiring orthopedic splinting, care of the pediatric patient requiring ophthalmic interventions, providing care for the pediatric patient receiving a lumbar puncture, assessment and cleansing of wound, application of local anesthetic, utilization of sterile technique, performing wound repair, wound care education, Mik-Key G-button replacement, Central Line repairs, medication administration/calculation test, blood culture collection, suturing, lidocaine administration, restraint application/seclusion, glucometer testing, C-spine immobilization, and crutch training.


The hospital's March 2016, last revised "Advanced Care Technician" (ACT/Paramedic) job description reflected, "provide competent and skilled care to patients and families at (name of hospital) under the direction of a physician or nurse. Provides support functions related to operations and supplements the health care team. Does not work independently or practices as a licensed individual...Responsibilities: Physician Delegated Procedures: Performs the following procedures with written order and supervision of a licensed physician...Antipyretics - PO Acetaminophen, Ibuprofen...Topical miscellaneous meds - topical admixtures of Neosporin, Silvadine Auralgan, Cerumenex, and LET...PO (by mouth) miscellaneous meds - Albuterol, Activated Charcoal, Prelone, Bendadryl, Orapred, Atarax, Zofran...Nebulization treatments for Respiratory distress - Albuterol, Ipratropium Bromide, Epinephrine, Lidocaine, Terbutaline, Atropine as prescribed by physician using standard dose based on weight...Subcutaneous (SQ) infiltration of lacerations - Lidocaine 1% with or without Epinephrine, Neut...Catheters - Insertion of urethral bladder catheters and insertion of nasogastric catheters...Wound care - would cleansing, irrigation and infiltration with Lidocaine, application of sterile dressings....Oxygenation - application and monitoring of oxygen...Peripheral venipuncture...Application of extremity splints and bandage...Fits and adjusts crutches, instructs patients in proper crutch walking...Suture and staple removal...Oral, nasal, naso-tracheal, and endo-tracheal suction...Otic (ear) irrigations...Performs non-invasive procedures such as specimen collection, obtaining vital signs, monitoring pulse oximetry according to department policy and documents appropriately in the medical record...


Nurse Delegated Procedures: Performs the following procedures as delegated by a registered nurse...Witnesses the withdrawal and waste of narcotics in the Omni-cell...Transports medication pulled from the Omni-cell by a licensed practitioner to another unit if needed...Assessment: Demonstrates effectiveness in assessment and/or problem solving abilities. Recognizes deviations from normal or baseline and reports changes to the physician and registered nurse. Uses professional judgment in the performance of job duties...Knows limitations and reports pertinent information to the registered nurse or nurse manager...Adheres to policies and procedures as well as regulatory standards...performs validated procedures with written order and supervision of a licensed physician and/or delegation by a registered nurse...Documents patient interventions and responses clearly and accurately...Demonstrates flexibility and ability to work without close supervision."


The hospital's 9/26/16, approved "Wound Care Tech Addendum Page" job description for the paramedics stated, "The Wound Management Tech, Advanced Care Tech (ACT), will provide specified technical care to children with a wide range of injuries and illnesses with a special focus on wound management. Implements appropriate treatment for patient wound care requirements as determined by the supervising physician and set forth in unit policy. Provides support functions related to operations and supplements the health care team. Does not work independently or practice as a licensed individual..


RESPONSIBILITIES...Physician Delegated Procedures: Performs the following procedures with written order and supervision of a licensed physician...Administration of anesthesia (topical, infiltrate, digital block); to include Lidocaine, Marcaine, with or without Epinephrine...Performs minor surgical procedures for approved wound repairs involving trephination, nail plate removal, debridement, irrigation, suturing skin and subcutaneous tissue and fascia, stapling and dressing application...Reviews data provided by screening personnel and reports findings to physician, performs wound injury assessments and documents patient's status with subjective and objective data, documents wound management according to protocol including preparation, response to therapies and discharge instructions."


There was no quality of care measures documented to monitor care provided by the paramedics was within their scope of practice for a Healthcare Facility setting.


During an interview on 3/08/17 at 1:30 PM, Personnel #2 was asked how the paramedics are functioning. Personnel #2 stated, "They are an extra pair of hands. In pre-op (Pre-operative area), they start (intravenous catheters) IV's, DC (discontinue post-operatively) IV'S, take patients to the car."


During an interview on 3/9/17 at 9:45 AM, Personnel #2 was asked about the (wound care paramedic) and how they function. Personnel #2 stated, "They give lidocaine and suture."


During an interview on 3/08/17 at 2:00 PM in the ER (emergency room), Personnel #21, was asked about the role the paramedics play in the ER. Personnel #21 stated, "Give PO (by mouth) medications, take vital signs, splint, venipunctures, and point of care strep (testing)." Personnel #21 was asked who the paramedics work under. Personnel #21 stated, "the nurse."


TITLE 22 EXAMINING BOARDS, PART 9 TEXAS MEDICAL BOARD, CHAPTER 197 EMERGENCY MEDICAL SERVICE


RULE §197.7 Physician Supervision of Emergency Medical Technician-Paramedic or Licensed Paramedic Care Provided in a Health Care Facility Setting (provide Advanced Life Support in the facility)...Advanced life support--Health care provided to sustain life in an emergency, life-threatening situation...Direct supervision - Supervision by a licensed physician who is present in the same area or an area adjacent to the area where an emergency medical technician-paramedic or licensed paramedic performs a procedure and who is immediately available to provide assistance and direction during the performance of the procedure...a person who is certified as an EMT-P or a LP, is acting under the delegation and direct supervision of a licensed physician, and is authorized to provide advanced life support by a health care facility, may in accordance with DSHS rules provide advanced life support in the facility's emergency or urgent care clinical setting, including a hospital emergency room and a freestanding emergency medical care facility...The supervising physician may use protocols, which may include standing delegation orders. Such instructions may not be used in lieu of communication with the supervising physician or of obtaining the physician's physical assistance and direction during the performance of a procedure...The physician who delegates to and directly supervises advanced life support in a healthcare facility as authorized in this section remains professionally and legally responsible for the patient care provided by the EMT-P or LP...The physician who delegates to and directly supervises an EMT-P or LP providing advanced life support must ensure that the EMT-P or LP meets all requirements under the law related to creating and maintaining a medical record documenting the patient encounter...adopted to be effective April 3, 2016, 41 TexReg 2315


The BON (Texas Board of Nursing) 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.
https://www.bon.state.tx.us/faq_delegation.asp#t7 - Paramedics/EMTs in the Emergency Department (ED)...Can an RN delegate starting a peripheral IV saline lock to an EMT/Paramedic in the Emergency Department (ED)? Some of the "techs" in our ED are "licensed paramedics" who also work for EMS. What other kinds of tasks can be delegated to Emergency Medical Technicians (EMTs)/Paramedics in the ED setting...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...The BON's delegation Rule 224 is not prescriptive to specific procedures or tasks that may or may not be delegated. Rule 224 permits an RN to delegate starting a peripheral IV saline lock to an unlicensed person providing all of the delegation criteria are met...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."


TITLE 22 EXAMINING BOARDS, PART 11 TEXAS BOARD OF NURSING, CHAPTER 224 DELEGATION OF NURSING TASKS BY REGISTERED PROFESSIONAL NURSES TO UNLICENSED PERSONNEL FOR CLIENTS WITH ACUTE CONDITIONS OR IN ACUTE CARE ENVIRONMENTS...Rule §224.8, "Delegation of Tasks...Discretionary Delegation Tasks...the manner in which the unlicensed person demonstrates competency of the delegated task...the mechanism for reevaluation of the competency...periodic re-demonstration of competency...the following are nursing tasks that are not usually within the scope of sound professional nursing judgment to delegate...sterile procedures-those procedures involving a wound or an anatomical site which could potentially become infected...non-sterile procedures, such as dressing or cleansing penetrating wounds and deep burns...invasive procedures-inserting tubes in a body cavity or instilling or inserting substances into an indwelling tube; and care of broken skin other than minor abrasions or cuts generally classified as requiring only first aid treatment...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...physical, psychological, and social assessment which requires professional nursing judgment, intervention, referral, or follow-up...formulation of the nursing care plan and evaluation of the client's response to the care rendered...the responsibility and accountability for client health teaching and health counseling (discharge instructions) which promotes client education and involves the client's significant others in accomplishing health goals; and 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)..." and


Rule §224.5, "RN Accountability for Delegated Tasks The RN nurse administrator or the RN who is responsible for nursing services in settings that utilize RN delegation in clients with acute care conditions or acute care environments shall be responsible for knowing the requirements of this rule and for taking reasonable steps to assure that registered nurse delegation is implemented and conducted in compliance with the Texas Nursing Practice Act and this chapter..."

Based on record review and interview, the hospital failed to inform each patient/parent of its process for prompt resolution of a patient/parent grievance including whom to contact to file a grievance, in that, 14 of 14 patient (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14) medical records did not document a signed copy of the patient's bill of rights to include its process for prompt resolution of a patient/parent grievance including whom to contact to file a grievance (at the hospital or the Department) from each patient/parent.


Findings included


Patient #1's, #2's, #3's, #4's, #5's, #6's, #7's, #8's, #9's, #10's, #11's, #12's, #13's, and #14's medical records did not document a signed copy of the patient's bill of rights to include its process for prompt resolution of a patient/parent grievance including whom to contact to file a grievance from each patient/parent.


The February 2016, last revised, hospital "Consent for Treatment" reflected, "If I or my child is being admitted...I will be given written information on the rights and responsibilities of the patient..."


During an interview on 3/08/17 at 4:00 PM, Personnel #2 was informed the consent did not reflect the patient/parent receipt of the rights to include its process for prompt resolution of a patient/parent grievance including whom to contact to file a grievance. Personnel #2 reviewed the consent and agreed. Personnel #2 was asked if the patient/parent signed any other document for the receipt of patient rights. Personnel #2 stated, "No." Personnel #2 provided a handout and stated, "We given them a handout." Personnel #2 was informed the handout did not include to whom or where to file a grievance at the hospital or the Department. Personnel #2 reviewed the handout and stated, "It does not."

Based on record review and interview, the Governing Body failed to ensure quality medical services are provided in a safe and effective manner in a safe setting that permits the hospital to comply with all applicable rules and standards. The Governing Body, Medical Staff and Chief Nursing Officer directed and allowed paramedics to function outside their scope of practice (Scope includes: provide Advanced Life Support in the facility and/or function as an unlicensed personnel) while providing patient care in a Healthcare Facility Setting.


Findings included:


The hospital personnel list provided on 3/08/17 included one paramedic (Personnel #28) working in surgery, 2 paramedics (Personnel # 51 and #52) working in emergency room, and 5 paramedics (Personnel #30, #53, #54, #55 and #56) working in Urgent Care.


Personnel (Paramedic) #23's skills checklist reflected competencies completed on 8/14/08 (with some updates in May 2016) for Operating room equipment competencies, medication administration competency exam, Alaris IV Pump, i-Stat training test, orthopedic splinting, suturing lacerations, blood cultures, urinary catheterization, intravenous access, Nasogastric/Orogastric tube insertion, blood product administration, malignant hyperthermia, restraints application, crutch training, blood transfusion administration, cervical spine immobilization, and EKG rhythm recognition.


Personnel (Paramedic) #24's skills checklist reflected competencies completed on 5/22/08 (with some updates on 3/31/16) for medication calculation test, blood transfusion test, competency for Alaris IV pump, IV catheter insertion competency, SureStep Glucometer, i-Stat, Group A Rapid Strep, Blood Sample collection competency test, assessment and cleansing of wound, application of local anesthetic, utilization of sterile technique, performing wound repair, wound care education, training with Loopes, Mik-Key G-button replacement, Central Line repairs, medication administration/calculation test, blood culture collection, suturing, lidocaine administration, restraint application/seclusion, glucometer testing, C-spine immobilization, crutch training, EKG rhythm recognition testing, suturing of lacerations competency, and EKG rhythm recognition testing.


Personnel (Paramedic) #28 skills checklist reflected competencies completed on 1/17/14 (with some updates on 8/19/16) for intravenous access on the pediatric patient, insertion of NG/OG tubes, lavage procedure, urinary catheterization, orthopedic splinting, soft tissue injury, vein illumination skills, and medication administration test.


Personnel (Paramedic) #29 skills checklist reflected competencies completed on 6/07/16 for restraint/seclusion, IV access competency checklist, blood culture collection, insertion of OG/NG tubes, lavage procedure, urinary catheterization, care of patient receiving urinary catheterization care of patient requiring orthopedic splinting,


Personnel (Paramedic) #30 skills checklist reflected competencies completed on 12/08/15 (with some updates on 12//03/16) for IV access, Alaris IV Pump module, insertion of OG/NG tube, lavage procedure, urinary catheterization, and orthopedic splinting.


Personnel (Paramedic) #31 skills checklist reflected competencies completed on 9/15/15, with some updates on 3/29/16 for the Alaris IV pump, IV access, medication dosage calculations, insertion of nasogastric tubes, restraint use, glucose testing, clean catch urine collection, insertion of urinary catheterization, and orthopedic splinting.


Personnel (Paramedic) #32 skills checklist reflected competencies completed on 11/02/11 (with some updates on 4/19/16) for intravenous medication administration, insertion of oral and nasogastric tubes, urinary catheterization, soft tissue injury, orthopedic splinting, crutch training, application of local anesthetic, performing wound repair, blood culture collection procedure, medication administration test, and blood culture collection.


Personnel (Paramedic) #33 skills checklist reflected competencies completed on 10/07/11 (with some updates on 3/21/16) for intravenous Therapy of the pediatric patient, insertion of OG(oral-gastric)/NG (naso-gastric) tubes, urinary catheterization, collection of urinary specimen, providing care to pediatric patients with soft tissue injuries, providing care to the pediatric patient requiring orthopedic splinting, care of the pediatric patient requiring ophthalmic interventions, providing care for the pediatric patient receiving a lumbar puncture, assessment and cleansing of wound, application of local anesthetic, utilization of sterile technique, performing wound repair, wound care education, Mik-Key G-button replacement, Central Line repairs, medication administration/calculation test, blood culture collection, suturing, lidocaine administration, restraint application/seclusion, glucometer testing, C-spine immobilization, and crutch training.


The hospital's March 2016, last revised "Advanced Care Technician" (ACT/Paramedic) job description reflected, "provide competent and skilled care to patients and families at (name of hospital) under the direction of a physician or nurse. Provides support functions related to operations and supplements the health care team. Does not work independently or practices as a licensed individual...Responsibilities: Physician Delegated Procedures: Performs the following procedures with written order and supervision of a licensed physician...Antipyretics - PO Acetaminophen, Ibuprofen...Topical miscellaneous meds - topical admixtures of Neosporin, Silvadine Auralgan, Cerumenex, and LET...PO (by mouth) miscellaneous meds - Albuterol, Activated Charcoal, Prelone, Bendadryl, Orapred, Atarax, Zofran...Nebulization treatments for Respiratory distress - Albuterol, Ipratropium Bromide, Epinephrine, Lidocaine, Terbutaline, Atropine as prescribed by physician using standard dose based on weight...Subcutaneous (SQ) infiltration of lacerations - Lidocaine 1% with or without Epinephrine, Neut...Catheters - Insertion of urethral bladder catheters and insertion of nasogastric catheters...Wound care - would cleansing, irrigation and infiltration with Lidocaine, application of sterile dressings....Oxygenation - application and monitoring of oxygen...Peripheral venipuncture...Application of extremity splints and bandage...Fits and adjusts crutches, instructs patients in proper crutch walking...Suture and staple removal...Oral, nasal, naso-tracheal, and endo-tracheal suction...Otic (ear) irrigations...Performs non-invasive procedures such as specimen collection, obtaining vital signs, monitoring pulse oximetry according to department policy and documents appropriately in the medical record.."


Nurse Delegated Procedures: Performs the following procedures as delegated by a registered nurse...Witnesses the withdrawal and waste of narcotics in the Omni-cell...Transports medication pulled from the Omni-cell by a licensed practitioner to another unit if needed...Assessment: Demonstrates effectiveness in assessment and/or problem solving abilities. Recognizes deviations from normal or baseline and reports changes to the physician and registered nurse. Uses professional judgment in the performance of job duties...Knows limitations and reports pertinent information to the registered nurse or nurse manager...Adheres to policies and procedures as well as regulatory standards...performs validated procedures with written order and supervision of a licensed physician and/or delegation by a registered nurse...Documents patient interventions and responses clearly and accurately...Demonstrates flexibility and ability to work without close supervision."


The hospital's 9/26/16, approved "Wound Care Tech Addendum Page" job description for the paramedics stated, "The Wound Management Tech, Advanced Care Tech (ACT), will provide specified technical care to children with a wide range of injuries and illnesses with a special focus on wound management. Implements appropriate treatment for patient wound care requirements as determined by the supervising physician and set forth in unit policy. Provides support functions related to operations and supplements the health care team. Does not work independently or practice as a licensed individual.


RESPONSIBLITIES...Physician Delegated Procedures: Performs the following procedures with written order and supervision of a licensed physician...Administration of anesthesia (topical, infiltrate, digital block); to include Lidocaine, Marcaine, with or without Epinephrine...Performs minor surgical procedures for approved wound repairs involving trephination, nail plate removal, debridement, irrigation, suturing skin and subcutaneous tissue and fascia, stapling and dressing application...Reviews data provided by screening personnel and reports findings to physician, performs wound injury assessments and documents patient's status with subjective and objective data, documents wound management according to protocol including preparation, response to therapies and discharge instructions."


There was no quality of care measures documented to monitor care provided to patients by the paramedics was within their scope of practice for a Healthcare Facility setting.


During an interview on 3/08/17 at 1:30 PM, Personnel #2 was asked how the paramedics are functioning. Personnel #2 stated, "They are an extra pair of hands. In pre-op (Pre-operative area), they start (intravenous catheters) IV's, DC (discontinue post-operatively) IV'S, take patients to the car."


During an interview on 3/9/17 at 9:45 AM, Personnel #2 was asked about the (wound care paramedic) and how they function. Personnel #2 stated, "They give lidocaine and suture."


During an interview on 3/08/17 at 2:00 PM in the ER (emergency room), Personnel #21, was asked about the role the paramedics play in the ER. Personnel #21 stated, "Give PO (by mouth) medications, take vital signs, splint, venipunctures, and point of care strep (testing)." Personnel #21 was asked who the paramedics work under. Personnel #21 stated, "the nurse."

Based on record review and interview, the facility failed to take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained, in that, the hospital did not have Quality Assessment and Performance Improvement Committee Meetings to document actions completed aimed at performance improvement, or to measure success and track performance to ensure that improvements were made and sustained for 2016 and 2017.


Findings included


There were no minutes for Quality Assessment and Performance Improvement Committee Meetings for 2016 or 2017.


The "QAPI Plan Grid" reflected, "Department (multiple)/Aspect of care/Opportunity Identified/Approach Staff Leader/Timelines...AR days over 35 negatively impact collections...June 1, 2015...Ongoing (no update)...staff do not have access to meditech to provide medication reconciliation...education needed...June 2, 2016...clinical staff not documenting PPE (Personal Protective Equipment)...chart audits...May 5, 2016...Forms are not reviewed and/or revised within 2 year timeframe required by our policy...April 1, 2015 Ongoing...Delays in MRI start times...Will monitor...March 2, 2015 Ongoing...Physicians not signing their telephone/verbal orders within 48 hours...text or email...May 1, 2015 Ongoing...Workstations on Wheels...have no electrical inspections...annually...September 9, 2015 Ongoing...Blood Culture Contamination...re-educate...monitor...February 1, 2013 ongoing...Time-out Documentation...could lead to possible jeopardy in patient safety...August 1, 2016 Ongoing..."


There were no new opportunities to the QAPI Grid since August 2016 or updated actions since September 2016. There were no documented evaluations of plans at the 30, 60 and 90 day mark.


There was no mention of discussion of the "QAPI Plan Grid" or evaluation of overall effectiveness in the October and November 2016 MEC (Medical Executive Committee) meeting minutes reviewed.


There were no new opportunities to the QAPI Grid since August 2016 or updated actions since September 2016. The Grid did not document completed actions/times taken to improve.


The January 2017, last revised "Quality Assurance and Performance Improvement Plan" required, "The Board has delegated oversight of the (Hospital name/initials) Quality Management Plan to the MEC...Performance Improvement Plans will be initiated annually based on the criteria...Plans will be monitored with updates and evaluation of plans at the 30, 60 and 90 days marks by the Department Manager...overall effectiveness will be evaluated at least annually by the MEC (Medical Executive Committee)."


During an interview on 3/08/17 at 10:05 AM, Personnel #4 (Infection Control) was informed of the above findings. Personnel #4 stated, "I attend the EOC (Environment of Care) meeting, but we just talk about an overview of incidents and infections. We don't look at the data collected. I give the information to the CNO. I do not go to the MEC meeting."


During an interview on 3/08/17 at 10:25 AM, Personnel #3 (Quality Manager) was informed of the above findings. Personnel #3 stated, "We don't have a Quality Committee meeting. I facilitate putting the MEC binder together for their meeting. The Department Tracking (QAPI Grid) is not included in the meeting. During the meetings, we just talk about an overview, not specifics. The departments are looking at the Grid items. I don't sit on the Board."

Based on record review and interview, the medical staff failed to ensure an updated examination of the patient, including any changes in the patient's condition was completed and documented by a physician within 24 hours after admission for patients with an accepted H&P (history and physical) that was within the 30 days of admission, in that, 5 of 14 patient (Patient #3, #11, #12, #13, and #14) medical records did not document an updated examination of the patient, including any changes in the patient's condition was completed and documented by a physician within 24 hours after admission for patients with an accepted H&P (history and physical) that was within the 30 days of admission.


Findings included


Patient #3's, #11's, #12's, #13's, and #14's medical records did not document an updated examination of the patient, including any changes in the patient's condition was completed and documented by a physician within 24 hours after admission for patients with an accepted H&P (history and physical) that was within the 30 days of admission.


During an interview on 3/09/17 ending 2:40 PM, Personnel #50 was asked for the updated examination of the patient, including any changes in the patient's condition was completed and documented by a physician within 24 hours after admission for patients with an accepted H&P (history and physical) that was within the 30 days of admission. Personnel #50 explained the patient had outpatient surgery and then was admitted post surgery. Personnel #50 was unable to find an update to the H&P within 24 hours after admission.


During an interview on 3/09/17 ending at 2:50 PM, Personnel #2 was informed of the above finding. Personnel #2 was asked for documentation of an update to the H&P after the patient admission time. Personnel #2 did not provide further documentation.

Based on record review and interview, the hospital failed to have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care, in that,

the Chief Nursing Officer directed and allowed paramedics to function outside their scope of practice (Scope includes: provide Advanced Life Support in the facility and/or function as an unlicensed personnel) while providing patient care in a Healthcare Facility Setting.


Findings included:


The hospital personnel list provided on 3/08/17 included one paramedic (Personnel #28) working in surgery, 2 paramedics (Personnel # 51 and #52) working in emergency room, and 5 paramedics (Personnel #30, #53, #54, #55 and #56) working in Urgent Care.


Personnel (Paramedic) #23's skills checklist reflected competencies completed on 8/14/08 (with some updates in May 2016) for Operating room equipment competencies, medication administration competency exam, Alaris IV Pump, i-Stat training test, orthopedic splinting, suturing lacerations, blood cultures, urinary catheterization, intravenous access, Nasogastric/Orogastric tube insertion, blood product administration, malignant hyperthermia, restraints application, crutch training, blood transfusion administration, cervical spine immobilization, and EKG rhythm recognition.


Personnel (Paramedic) #24's skills checklist reflected competencies completed on 5/22/08 (with some updates on 3/31/16) for medication calculation test, blood transfusion test, competency for Alaris IV pump, IV catheter insertion competency, SureStep Glucometer, i-Stat, Group A Rapid Strep, Blood Sample collection competency test, assessment and cleansing of wound, application of local anesthetic, utilization of sterile technique, performing wound repair, wound care education, training with Loopes, Mik-Key G-button replacement, Central Line repairs, medication administration/calculation test, blood culture collection, suturing, lidocaine administration, restraint application/seclusion, glucometer testing, C-spine immobilization, crutch training, EKG rhythm recognition testing, suturing of lacerations competency, and EKG rhythm recognition testing.


Personnel (Paramedic) #28 skills checklist reflected competencies completed on 1/17/14 (with some updates on 8/19/16) for intravenous access on the pediatric patient, insertion of NG/OG tubes, lavage procedure, urinary catheterization, orthopedic splinting, soft tissue injury, vein illumination skills, and medication administration test.


Personnel (Paramedic) #29 skills checklist reflected competencies completed on 6/07/16 for restraint/seclusion, IV access competency checklist, blood culture collection, insertion of OG/NG tubes, lavage procedure, urinary catheterization, care of patient receiving urinary catheterization care of patient requiring orthopedic splinting,


Personnel (Paramedic) #30 skills checklist reflected competencies completed on 12/08/15 (with some updates on 12//03/16) for IV access, Alaris IV Pump module, insertion of OG/NG tube, lavage procedure, urinary catheterization, and orthopedic splinting.


Personnel (Paramedic) #31 skills checklist reflected competencies completed on 9/15/15, with some updates on 3/29/16 for the Alaris IV pump, IV access, medication dosage calculations, insertion of nasogastric tubes, restraint use, glucose testing, clean catch urine collection, insertion of urinary catheterization, and orthopedic splinting.


Personnel (Paramedic) #32 skills checklist reflected competencies completed on 11/02/11 (with some updates on 4/19/16) for intravenous medication administration, insertion of oral and nasogastric tubes, urinary catheterization, soft tissue injury, orthopedic splinting, crutch training, application of local anesthetic, performing wound repair, blood culture collection procedure, medication administration test, and blood culture collection.


Personnel (Paramedic) #33 skills checklist reflected competencies completed on 10/07/11 (with some updates on 3/21/16) for intravenous Therapy of the pediatric patient, insertion of OG(oral-gastric)/NG (naso-gastric) tubes, urinary catheterization, collection of urinary specimen, providing care to pediatric patients with soft tissue injuries, providing care to the pediatric patient requiring orthopedic splinting, care of the pediatric patient requiring ophthalmic interventions, providing care for the pediatric patient receiving a lumbar puncture, assessment and cleansing of wound, application of local anesthetic, utilization of sterile technique, performing wound repair, wound care education, Mik-Key G-button replacement, Central Line repairs, medication administration/calculation test, blood culture collection, suturing, lidocaine administration, restraint application/seclusion, glucometer testing, C-spine immobilization, and crutch training.


The hospital's March 2016, last revised "Advanced Care Technician" (ACT/Paramedic) job description reflected, "provide competent and skilled care to patients and families at (name of hospital) under the direction of a physician or nurse. Provides support functions related to operations and supplements the health care team. Does not work independently or practices as a licensed individual...Responsibilities: Physician Delegated Procedures: Performs the following procedures with written order and supervision of a licensed physician...Antipyretics - PO Acetaminophen, Ibuprofen...Topical miscellaneous meds - topical admixtures of Neosporin, Silvadine Auralgan, Cerumenex, and LET...PO (by mouth) miscellaneous meds - Albuterol, Activated Charcoal, Prelone, Bendadryl, Orapred, Atarax, Zofran...Nebulization treatments for Respiratory distress - Albuterol, Ipratropium Bromide, Epinephrine, Lidocaine, Terbutaline, Atropine as prescribed by physician using standard dose based on weight...Subcutaneous (SQ) infiltration of lacerations - Lidocaine 1% with or without Epinephrine, Neut...Catheters - Insertion of urethral bladder catheters and insertion of nasogastric catheters...Wound care - would cleansing, irrigation and infiltration with Lidocaine, application of sterile dressings....Oxygenation - application and monitoring of oxygen...Peripheral venipuncture...Application of extremity splints and bandage...Fits and adjusts crutches, instructs patients in proper crutch walking...Suture and staple removal...Oral, nasal, naso-tracheal, and endo-tracheal suction...Otic (ear) irrigations...Performs non-invasive procedures such as specimen collection, obtaining vital signs, monitoring pulse oximetry according to department policy and documents appropriately in the medical record...


Nurse Delegated Procedures: Performs the following procedures as delegated by a registered nurse...Witnesses the withdrawal and waste of narcotics in the Omni-cell...Transports medication pulled from the Omni-cell by a licensed practitioner to another unit if needed...Assessment: Demonstrates effectiveness in assessment and/or problem solving abilities. Recognizes deviations from normal or baseline and reports changes to the physician and registered nurse. Uses professional judgment in the performance of job duties...Knows limitations and reports pertinent information to the registered nurse or nurse manager...Adheres to policies and procedures as well as regulatory standards...performs validated procedures with written order and supervision of a licensed physician and/or delegation by a registered nurse...Documents patient interventions and responses clearly and accurately...Demonstrates flexibility and ability to work without close supervision."


The hospital's 9/26/16, approved "Wound Care Tech Addendum Page" job description for the paramedics stated, "The Wound Management Tech, Advanced Care Tech (ACT), will provide specified technical care to children with a wide range of injuries and illnesses with a special focus on wound management. Implements appropriate treatment for patient wound care requirements as determined by the supervising physician and set forth in unit policy. Provides support functions related to operations and supplements the health care team. Does not work independently or practice as a licensed individual.


RESPONSIBLITIES...Physician Delegated Procedures: Performs the following procedures with written order and supervision of a licensed physician...Administration of anesthesia (topical, infiltrate, digital block); to include Lidocaine, Marcaine, with or without Epinephrine...Performs minor surgical procedures for approved wound repairs involving trephination, nail plate removal, debridement, irrigation, suturing skin and subcutaneous tissue and fascia, stapling and dressing application...Reviews data provided by screening personnel and reports findings to physician, performs wound injury assessments and documents patient's status with subjective and objective data, documents wound management according to protocol including preparation, response to therapies and discharge instructions."


There was no quality of care measures documented to monitor care provided to patients by the paramedics was within their scope of practice for a Healthcare Facility setting.


During an interview on 3/08/17 at 1:30 PM, Personnel #2 was asked how the paramedics are functioning. Personnel #2 stated, "They are an extra pair of hands. In pre-op (Pre-operative area), they start (intravenous catheters) IV's, DC (discontinue post-operatively) IV'S, take patients to the car."


During an interview on 3/9/17 at 9:45 AM, Personnel #2 was asked about the (wound care paramedic) and how they function. Personnel #2 stated, "They give lidocaine and suture."


During an interview on 3/08/17 at 2:00 PM in the ER (emergency room), Personnel #21, was asked about the role the paramedics play in the ER. Personnel #21 stated, "Give PO (by mouth) medications, take vital signs, splint, venipunctures, and point of care strep (testing)." Personnel #21 was asked who the paramedics work under. Personnel #21 stated, "the nurse."