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Based on record review and interview, the hospital failed to meet the requirements for the Condition of Participation for Nursing Services as evidenced by failing to ensure patients had been assessed to determine if they met the criteria for delegation of nursing care by the RN (registered nurse) to the LPN (Licensed Practical Nurse) according to the LSBN's "Administrative Rules Defining RN Practice LAC46: XLVII §3703. Definition of Terms Applying to Nursing Practice".

This was evidenced by the RN assigning responsibility for 2 (#3, (current pt), #4) ventilated patients receiving continuous infusions of medications out of a total of 5 patients in the High Observation Unit on 3/28/15, also assigning responsibility to an LPN for 1 current (#6) ventilated patient receiving continuous infusions of medications in the High Observation Unit on 4/27/15. (See findings in tag A-0397).

Based on interview and record review, the hospital failed to ensure patients had been assessed to determine if they met the criteria for delegation of nursing care by the RN (registered nurse) to the LPN (Licensed Practical Nurse) according to the LSBN's "Administrative Rules Defining RN Practice LAC46: XLVII §3703. Definition of Terms Applying to Nursing Practice". This was evidenced by the RN assigning responsibility for 2 (#3, (current pt), #4) ventilated patients receiving continuous infusions of medications out of a total of 5 patients in the High Observation Unit on 3/28/15, also assigning responsibility to an LPN for 1 current (#6) ventilated patient receiving continuous infusions of medications in the High Observation Unit (5 patient unit for more critical patients requiring a higher level of care) on 4/27/15.

Findings:

Review of the LSBN's "Administrative Rules Defining RN Practice LAC46: XLVII §3703. Definition of Terms Applying to Nursing Practice" revealed that the RN retains the accountability for the total nursing care of the individual and is responsible for and accountable to each consumer of nursing care for the quality of nursing care he or she receives, regardless of whether the care is provided solely by the RN or by the RN in conjunction with other licensed or unlicensed assistive personnel. The RN shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems. This assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required. Any situation where tasks are delegated should meet the following criteria:

a) the person has been adequately trained for the task;
b) the person has demonstrated that the task has been learned;
c) the person can perform the task safely in the given nursing situation;
d) the patient's status is safe for the person to carry out the task;
e) appropriate supervision is available during the task implementation;
f) the task is in an established policy of the nursing practice setting and the policy is written, recorded and available to all.

Further review revealed the RN may delegate to LPNs the major part of the nursing care needed by individuals in stable nursing situations, i.e., when the following three conditions prevail at the same time in a given situation:

a) nursing care ordered and directed by the RN or physician requires abilities based on a
relatively fixed and limited body of scientific fact and can be performed by following a
defined nursing procedure with minimal alteration, and responses of the individual to the
nursing care are predictable; and

b) change in the patient's clinical conditions is predictable; and

c) medical and nursing orders are not subject to continuous change or complex
modification.

Review of the Declaratory Statement by the Louisiana State Board of Nursing on the Role and Scope of Practice of Registered Nurses Delegating IV (Intravenous ) Therapy Interventions, adopted 5/12/99, reaffirmed, revealed the following, in part:

Based on the agency's written policy, the RN's assessment of the patient and availability of the RN to supervise the implementation of the delegated intervention and evaluate the patient's response to therapy, the RN may delegate certain IV therapy interventions to an LPN. An RN may delegate to an LPN the major part of the nursing care needed by individuals in stable nursing situations, when the three conditions (a, b & c referenced above) prevail at the same time, in a given situation.

The following nursing intervention may not be delegated in any practice setting, in accordance with the Board's rules (LAC 46: XLVII.3703.c):
Furthermore, the RN may not delegate the administration of medications requiring both titration and continuous patient assessment.

Based on the RN's assessment and accordance with the Board's rules on managing and supervising the practice of nursing, when the RN determines that the patient's condition is unstable, since the RN is accountable for the total nursing care rendered, the RN may initiate changes in nursing care or assignment of the nursing personnel and documentation.

Based on the RN's assessment and in accordance the Board believes that an RN may delegate an LPN selective IV therapy nursing interventions provided that RN supervision is readily available during implementation of the intervention, the patient's condition is determined non-complex and the LPN's level of competence is documented in said LPN's file.

A hospital policy regarding staffing assignment criteria was requested from the hospital's administrative staff. The survey team was informed by S2Quality that the hospital relied upon staff job descriptions for patient assignment and had no policies/procedures relative to criteria for determination of patient assignments.
Review of the hospital's position description for LVN (Licensed Vocational Nurse)/LPN revealed in part:

The LVN/LPN is responsible for providing age and population appropriate nursing care, as directed by a RN on the nursing unit. Functions include gathering and reporting data, carrying out orders, and performing therapeutic procedures on patients in an age and population -appropriate manner, consistent with the Nurse Practice Act of the state where the hospital resides and the policies, procedures and guidelines of this hospital. Performs related duties as assigned or requested.

I.Patient Care:
Under the direct supervision of a RN, assumes responsibility for the care of designated patients on designated shifts.
Performs assessments using appropriate techniques for data collection and analysis to make appropriate decisions for patient care and treatment within scope of responsibility, training and practice.
Performs diagnostic and therapeutic interventions within scope of practice and facility standards.

Review of the Staffing Grid on the High Observation Unit Staffing Sheet revealed the following:
5 patients: 2 RNs or 1RN and 1 LPN who is on the pull list
4 Patients: 2 RNs or 1 RN and 1LPN who is on the pull list
Please staff based on actual patient acuity for the below census:
3 Patients: 1 RN and 1 CNA (certified nursing assistant) unless there are 2 patients on vents/drips, then 2 nurses. CNA means CNA not an LPN functioning as a CNA.
2 Patients: 1 RN and 1 CNA unless there are 2 patients on vents/drips, then 2 nurses. CNA means CNA not an LPN functioning as a CNA.
1 patient: 1 RN


3/28/15:
Assigning responsibility for 2 (#3, #4) ventilated patients receiving continuous infusions of medications to an LPN in the High Observation Unit.

Review of the staffing sheets for the High Observation Unit on the day shift of 3/28/15 revealed S7LPN and S8LPN were listed as the staff nurses. S1CNO was also listed on the staffing sheets as the RN staff for that shift. No documented evidence of S1CNO's time of entry or exit on 3/28/15 was available due to her salaried status.
Patient #3

Review of Patient # 3's medical record revealed Patient #3 was admitted on 3/20/15. Further review revealed he was an inpatient in the High Observation Unit on 3/28/15 and was being managed on a ventilator with continuous infusions of Diprovan (Propofol)(hypnotic anesthetic) and Cardizem (relaxes the muscles of the heart and blood vessels).

Further review of Patient #3's medical record revealed the following nurses' notes entries:
3/28/15, 7:40 a.m.: Patient lying in bed. Eyes closed. Respirations even and unlabored. #8 ET (endotracheal tube) noted at 23 cm (centimeters) at the lip on right side of mouth. Vent (Ventilator) =SIMV (synchronized intermittent mandatory ventilation) =18, TV (tidal volume) = 500, FiO2 (fraction of inspired oxygen) = 50%, Rate=15, PEEP (positive end expiratory pressure) = 5. Diprovan at15 mcg (micrograms)/kg(kilogram)/min(minute). Cardizem at 5 ml (milliliters)/hr.(hour).Signed by S7LPN. Further review of Patient #3's narrative nurses notes revealed S7LPN cared for the patient on 3/28/15 from 06:40 a.m. until 14:30 p.m. without any documentation by a RN.
Additional review revealed the following entries were the only RN documentation in Patient #3's nurses' notes on 3/28/15:
3/28/15, 16:40 p.m.: decreased Diprovan to 10 mcg/kg per MD (medical doctor) order. Entry was signed S22RNCharge (from the Medical Surgical Unit).
3/28/15, 17:05 (5:05 p.m.) S1CNO administered IV (intravenous) push Dilaudid (narcotic pain reliever) 1 milligram (one time dose).
Patient # 4
Review of Patient # 4's medical record revealed he was admitted on 3/20/15 with admission diagnoses of Strep (Streptococcus) Pneumonia with Respiratory Insufficiency related to status post respiratory Failure and Renal Insufficiency. Further review revealed he was an inpatient in the High Observation Unit on 3/28/15.
Review of Patient #4's medical record revealed the following nurses' note entries:
3/28/15 06:40 a.m.: Received report. Signed by S7LPN.
3/28/15 07:35 a.m.: Pt. (patient) lying in bed, eyes closed to verbal stimuli. #8 ET tube noted at 24 cm on right side of mouth. Vent =SIMV =16, TV=500, FiO2 =40%, Rate=15, PEEP =5. Dopamine (increases blood pressure) at 3.3 mcg/kg/min. Diprovan (Propofol) (for sedation) at 15 mcg/kg/min. Signed by: S7LPN.
Further review of Patient #4's narrative nurses' notes revealed S7LPN documented care for this patient on 3/28/15 from 6:40 a.m. through 18:45 (6:45 p.m.) with no narrative note documentation by a RN noted for the duration of that shift.

4/27/15:
Assigning responsibility for 1 (#6) ventilated patient receiving continuous infusions of medications to an LPN in the High Observation Unit.

Review of Patient #6's medical record revealed she was admitted on 4/16/15 with the following diagnoses: Acute/Chronic Renal Failure, CHF (Congestive Heart Failure), Peritoneal Dialysis and Diabetes Mellitus, Type II. Further review revealed Patient #6 was being managed on Bi-Pap (Bi-level Positive Airway Pressure) and was receiving a continuous Dopamine (increases blood pressure) infusion on 4/27/15.

Review of the staffing sheet for the High Observation Unit dated 4/27/15, revealed S10LPN was assigned Patient #6.
Additional review of Patient #6' s medical record revealed the following nurses' notes entries:
4/27/15 19:40 p.m.: In bed resting. Generalized weakness noted. Initial assessment completed. See flowsheet. Cardiac monitoring in progress per telemetry. Bi-Pap 18/5, 8 Liters/Minute in use. Dopamine at 5 mcg/kg/min = 13.1 ml/hr. infusing to right wrist. Signed by S10LPN.
4/27/15 19:45 p.m.: Assessed pt. Agree with above. Care of pt. delegated to S10LPN. Further review revealed the entry was signed by S20RN delegating care to S10LPN.
Additional review of Patient #6's nurses' notes revealed S10LPN cared for Patient #6 from 19:40 p.m. to 06:05 a.m. on 4/27/15 with no other narrative note entries by a RN.
Review of Personnel files for S1CNO, S7LPN, S8LPN and S10LPN revealed no documented evidence of skills competencies for continuous medication administration. Further review of the skills competency evaluation tool revealed conscious sedation was marked as RN's only and was either left blank (S7LPN) or marked not applicable (S8LPN and S10LPN). Additional review of S1CNO's personnel file revealed no documented evidence of evaluation of skills competency for administration/monitoring of conscious sedation.
In an interview on 4/28/15 at 10:44 a.m. with S1CNO, she said the hospital's desire was to staff the High Observation Unit with two RNs, but sometimes they worked with LPNs that have ACLS (Advanced Cardiac Life Support) training. She indicated recently, on a Saturday, she had to come in because there was no RN coverage in the High Observation Unit. S1CNO said the RN scheduled for that shift had called in leaving 2 LPNs to staff the unit.
In an interview on 4/29/15 at 12:46 p.m. with S6Physician (Internal Medicine), he indicated the patients in the hospital ' s High Observation Unit were very sick patients who sometimes required drips for stabilization. He said he believed all of the nurses in the High Observation Unit should have been Registered Nurses with ICU (Intensive Care Unit) experience. S6Physician indicated he thought all of the nurses in the High Observation Unit were RNs with ICU experience.
In an interview on 4/29/15 at 1:17 p.m., with S2Quality, she indicated the goal was to have two RNs in the High Observation Unit, but they would use LPN coverage if they had to.
In an interview on 4/29/15 at 1:20 p.m., with S1CNO, she indicated she had been on Administrative call on 3/28/15 and she had come in at around 8:00 a.m. or so because the High Observation Unit RN had called in and there were only 2 LPNs available to staff the unit. She verified the LPNs were taking care of the patients and she was there to assist if needed. She agreed LPNs could not monitor patients on a Diprovan (Propofol) drip. S1CNO indicated she felt the patients were stable because they were receiving continuous medication drips (Cardizem, Diprovan and Dopamine). S1CNO agreed the patients ' conditions were not predictable. S1CNO confirmed S7LPN and S8LPN were the LPNs who had worked on 3/28/15. S1CNO indicated LPNs, under normal circumstances, would not be assigned to care for ventilator patients on drips.
In an interview on 4/30/15 at 1:00 p.m. with S8LPN, she said the day shift on 3/28/15 wasn't the first time two LPNs had worked in the High Observation Unit. S8LPN also said on 3/28/15 (day shift) she had walked into work and there had been 2 LPNs (S7LPN and herself) who had reported to work in the High Observation Unit. She indicated the RN from the night shift had given report to S7LPN. S8LPN said she told the charge RN from the night shift that she did not want to take any patients because they were ICU patients and a RN should have been taking care of them. S8LPN indicated she had felt the other LPN (S7LPN) was not qualified to care for the patients either. She explained that 4 of the patients were being managed on ventilators and the 5th patient was trached. S8LPN indicated she was not aware of any written hospital policies/guidelines for patients meeting criteria for assignment to LPN staff. S8LPN also indicated it was not within the scope of her practice to monitor patients receiving the types of continuous infusions Patients #3 and #4 had been receiving. She confirmed the LPNs had monitored the patients receiving drips and not S1CNO. S8LPN agreed patients on a ventilator with drips were complex and were not stable. S8LPN indicated S1CNO had administered IV push medications and had not assumed care of the patients when she came in on 3/28/15. S8LPN said S10LPN had a similar experience in the High Observation Unit. She indicated she should have done an incident report when she was assigned with another LPN in the High Observation Unit. S8LPN said she knew it was wrong and should not have taken the patients. S8LPN confirmed the RNs did not take over when patients' conditions changed for the worse. S8LPN indicated the hospital does not have enough RNs. She said sometimes the RN assessed all of the LPN's patients and sometimes they did not.
Attempts by hospital administrative staff to contact S7LPN for interview while the survey team was onsite were unsuccessful.
Attempts by hospital administrative staff to contact S10LPN for interview while the survey team was onsite were unsuccessful.

Based on record reviews, observation and interviews, the hospital failed to ensure the infection control officer implemented a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel as evidenced by:
1) Failure to ensure hand washing was performed after disposal of Bio-hazardous waste from a patient's room (#R5) who was on contact precautions for C. (Clostridium) Difficile;
2) Failure to ensure PPE (personal protective equipment) was removed properly after suctioning of a patient on contact isolation precautions. This deficient practice was evidenced by S19RT (respiratory therapist) using her contaminated gloves to remove her gown by grasping/tearing the neck of the gown and touching the neck and front of her scrubs with her contaminated gloves for 1 (#R4) of 1 patients observed receiving respiratory care;
3) Failure to ensure proper positioning of patient catheter bags to reduce the risk of urinary tract infections as evidenced by catheter bags touching/dragging the floor and/or having dependent loops for 2 (#3, #R3) of 2 patients observed with indwelling Foley catheters;
4) Failure to maintain a sanitary environment.
Findings:
1) Failure to ensure hand washing was performed after disposal of Bio-hazardous waste from a patient's room (#R5) who was on contact precautions for C. (Clostridium) Difficile;
On 4/28/15 at 9:40 a.m., an observation was made of S23CNA carrying a red Bio-hazard bag of waste to the Bio-hazardous waste room. She was carrying the bag with one gloved hand. She entered the room and disposed of the waste.
In an interview on 4/28/15 at 9:41 a.m. with S23CNA, she reported the Bio-hazardous waste bag she had discarded was from Patient #R5's room. She also confirmed the patient was on contact precautions for C. Difficile. S23CNA indicated she had used hand sanitizer after she had removed her gloves and had not washed her hands with soap and water.
In an interview on 4/28/15 at 9:42 a.m. with S9RN, Nurse Manager, she confirmed Patient #R5 was on contact precautions for a diagnosis of C. Difficile. She also confirmed S23CNA should have washed her hands with soap and water after glove removal because hand sanitizer was ineffective against C. Difficile.
2) Failure to ensure PPE was removed properly after suctioning of a patient (#R4) on contact isolation precautions.
Review of the hospital's policy titled "Donning and Removal of Personal Protective Equipment " , effective July 2013 and presented as a current policy by S2Quality, revealed the following, in part:
Policy: Use of Personal Protective Equipment (PPE) is wearing of items such as gowns, gloves, masks, and goggles to prevent contamination of clothing or skin with potentially infectious blood or body fluids. They should be used when there is a risk of this contamination. They are always to be used when with a patient on Contact Precautions.
Procedure: Removing PPE:
1.Non sterile gloves: Note that the outside of the glove is contaminated. Grab the outside of glove with the opposite hand from the outside, peel glove off and hold old glove in gloved hand. Slide the fingers of ungloved hand under the glove at the wrist and peel off. Place in trash.
2.Gown: Note that the front and sleeves of the gown are contaminated. Unfasten ties with ungloved hands and pull away from neck and shoulders, touching only the inside of the gown. Turn inside out, roll up, and place in trash.

On 4/30/15 at 10:40 a.m. an observation was made of S19RT suctioning Patient #R4's tracheostomy. Signage was noted on the patient's room indicating he was on contact precautions. S19RT was observed using her contaminated gloves to remove her gown by grasping/tearing the neck of the gown. S19RT touched the neck/front of her scrubs with her contaminated gloves. She was then observed balling the gown up and removing the gloves last after she had removed the gown.
S19RT was also observed providing care to Patient #R4 at 10:45 a.m. and she was again observed using her contaminated gloves to remove her gown by grasping/tearing the neck of the gown. S19RT touched the neck/front of her scrubs with her contaminated gloves.
In an interview on 4/30/15 at 10:48 a.m. with S2Quality, she confirmed the above referenced findings. S2Quality also confirmed S19RT should have removed her contaminated gloves and discarded them prior to removal of her gown. S2Quality indicated Patient #R4 was on contact precautions for Pseudomonas Aeruginosa.
3) Failure to ensure proper positioning of patient catheter bags to reduce the risk of urinary tract infections as evidenced by catheter bags touching/dragging the floor and/or having dependent loops:
Patient #R3
On 4/30/15 at 10:25 a.m. an observation was made of Patient #R3. He was seated upright in a cardiac chair. His catheter bag, approximately half full, was touching the floor and was positioned with a dependent loop.
In an interview on 4/30/15 at 10:30 a.m. S2Quality confirmed the above referenced observations. She also confirmed catheter bags should not be positioned with dependent loops or touching the floor. S2Quality indicated Patient #R3 was on contact precautions for MRSA (methicillin resistant staphylococcus aureus).
Patient #3
On 4/30/15 at 10:35 a.m. an observation was made of Patient #3. He was seated upright in a cardiac chair. Patient #3 ' s urine collection bag was three quarters full of urine. The collection bag was lying flat on the floor and a staff member was observed stepping on the bag. The catheter bag was hung on the side of the cardiac chair after it was picked up off of the floor and a dependent loop was noted.
In an interview on 4/30/15 at 10:45 a.m. S2Quality confirmed the above referenced observations. S2Quality indicated PT (physical therapy) staff had been repositioning Patient #3 when the catheter bag had been lying on the floor and was stepped on. She also indicated PT staff had been responsible for hanging the catheter with a dependent loop. S2Quality said PT staff needed to be reminded about proper positioning of catheter bags and catheter tubing.
4) Failure to maintain a sanitary environment.
On 4/28/15 at 9:20 a.m. following observation was made in the Clean Storage/Supply room ( located across from the entry to the High Observation Unit):
Review of a hospital document titled Infection Control revealed in part:
All patient equipment will be cleaned with approved products between each patient, using the appropriate wet times.

Review of a hospital document titled Patient Care Equipment Cleaning revealed in part:
Equipment Cleaning Directions:
1. Wipe down equipment.
9. Air dry
10. Install tag and bag equipment
11. Enter name of person cleaning equipment
12. Enter date of cleaning
14. Return clean equipment to storage area

1 Ventilator not bagged or tagged to indicate whether it was clean or dirty
In an interview on 4/28/15 at 9:21 a.m. with S9RN, Nurse Manager, she indicated she could not determine that the ventilator had been cleaned simply by appearance. S9RN explained the expectation was for clean equipment to be bagged and tagged by staff after cleaning.
On 4/28/15 at 9:30 a.m. the following observations were made in the clean equipment storage room on the Medical Surgical Unit hall:
4 Blood Pressure (BP) machines on a stand with attached baskets. The tubing of one of the machines was lying on the ground. Another of the BP machines had 4 packets of oral glucose solution, 3 alcohol wipes and a disposable digital thermometer (not marked with a patient name) in the basket. A third BP machine was noted to have a sheet with patient names and vital signs in the basket. The equipment had no signage to indicate it had been cleaned.
Oxygen Concentrator noted to have a coating of dust and a strip of masking tape. The equipment had no signage to indicate it had been cleaned.
In an interview on 4/28/15 at 9:31 a.m. with S9RN, she confirmed the blood pressure machines were multiple use and not dedicated to individual patients. She also confirmed the equipment was used on all patients, including those on contact precautions. S9RN agreed the supplies in the basket should have been discarded because they had potentially been in contact isolation patient rooms and could not be disinfected. S9RN indicated the above referenced equipment should have been disinfected with disinfecting wipes after use. She explained the hospital had 2 types of disinfecting wipes, one with hypochlorite for C. Difficile patients and another for standard disinfection.