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Based on clinical record review, policy and procedure review, personnel record review and staff interview, it was determined the hospital failed to ensure emergency care was provided to patients in accordance with acceptable standards of practice.

Findings:

a. The hospital failed to ensure the medical staff and the nursing services department provided adequate supervision and oversight of paramedics and emergency medical technicians providing care in the hospital emergency department. See A Tag 0395.

b. The medical staff and the nursing services departments failed to develop protocols and policies to delineation the scope of practice for EMTs and paramedics in the hospital emergency department. See A Tag 1112.

c. The hospital failed to ensure EMTs and paramedics were trained and had demonstrated skills competency for those tasks performed in the emergency department. See A Tag 1112.

Based on clinical record review and staff interview, it was determined the hospital failed to ensure an RN supervised and evaluated the care of each patient in the emergency room. Findings:

On 06/28/12, clinical records of four patients who received care in the emergency room were reviewed.

Three records (patients # 1, 3 and 4) documented a paramedic performed the initial comprehensive assessment of the patient's condition. There was no documentation a registered nurse contributed to, or validated the assessment.

One record (patient #2) documented care, including intravenous medication administration was provided by the paramedic and/or EMT. There was no documentation of oversight of the care by the RN.

At 2:45 p.m., Staff L was asked if paramedics performed patient triage and nursing assessments in the emergency department. She stated they did.

She was asked if they administered medications. She stated, "Yes."

She was asked if EMTs provided patient care in the emergency department. She stated they did.

Based on record review and staff interview, it was determined the hospital failed to ensure patient care assignments were made based on the qualifications and competency of staff. Findings:

On 06/28/12, personnel records were reviewed for nine clinical staff, including registered nurses, paramedics and emergency medical technicians, who provided nursing care to patients.

None of the eleven files had documentation of orientation specific to the hospital and to their respective departments.

None of the eleven files had skills competency validation.

The DON was informed of the findings at an exit conference held at the conclusion of the investigation. No other documentation was provided.

Based on record review, job description review and staff interview, it was determined the hospital failed to:

a. ensure a clear delineation of duties among the various types of emergency care personnel; and

b. failed to ensure staff working in the emergency room had demonstrated skills competencies. Findings:

1. A hospital job description for Emergency Department Registered Nurses documented the RN could delegate tasks to ER paramedics and unlicensed health care providers according to their documented competencies.

The job description did not document what tasks could be delegated to those caregivers.

A hospital job description titled, Paramedic, documented, "... Paramedic shall perform procedures at their level of licensure in accordance with guidelines and other delegated tasks they have been approved to do... Delegates appropriate and approved tasks they have been approved to do..."

The job description did not document what procedures and other tasks the paramedic was approved to do. The job description did not document what tasks the paramedic could delegate and to whom.

A hospital job description for Emergency Medical Technician I, had no documentation of job responsibilities in the hospital emergency department. The job description only addressed job responsibilities for patient care during pre-hospitalization.

On 06/28/12, the DON was asked if paramedics and emergency medical technicians provided patient care in the emergency department. She stated they did.

She was asked if the hospital had designated what tasks each care-giver was approved to do. She stated there was no such designation.

2. Personnel records for EMTs, paramedics and registered nurses were reviewed for evidence of demonstrated skills competencies for specialized tasks performed in the emergency room.

None of the records had documentation of skills competencies.

The findings were discussed with the DON at an exit conference held at the conclusion of the investigation. No additional documentation was provided.

Based on record review and staff interview, it was determined the hospital failed to ensure qualified staff performed respiratory care services. Findings:

A facility policy titled, After Hours Coverage of Respiratory Therapy Services, documented, "... After hours (11pm-7am shift) respiratory therapy will be covered by registered nurses... Respiratory will provide training to nursing personnel for procedures that are commonly done on night shift and a check off list for this training will be maintained in the nurse's education file..."

The policy did not document paramedics could provide respiratory therapy services.

On 06/28/12, the DON was asked what respiratory therapy treatments were provided by the nursing staff. She stated RNs and paramedics provided nebulizer treatments and arterial blood gases after hours.

She stated the paramedics provided respiratory therapy care only in the emergency department.

Clinical records for patients #1-4 were reviewed for evidence of respiratory care services. The records documented respiratory care treatments were performed by a paramedic or an RN.

The personnel records for seven clinical staff including registered nurses and paramedics were reviewed for evidence the staff had been trained and had demonstrated competency to provide respiratory therapy services.

Six of the seven files had no documentation of training or of skills competencies validation to perform nebulizer treatments or arterial blood gases.

Based on record review and interviews with hospital staff, the governing body through the Quality Assurance program does not ensure that staff providing care in the emergency department are competent, are working within their scope of practice and certification or licensure and have been approved to perform their duties in a safe manner.

Findings:

1. Personnel records for emergency medical technicians (EMTs), paramedics and registered nurses providing care in the emergency department were reviewed for evidence of demonstrated skills competencies for specialized tasks performed in the emergency room. None of the records had documentation of skills competencies.

2. The hospital job description for Emergency Department Registered Nurses documented the RN could delegate tasks to ER paramedics and unlicensed health care providers according to their documented competencies. The job description did not document what tasks could be delegated to those caregivers.

3. A hospital job description titled, Paramedic, documented, "... Paramedic shall perform procedures at their level of licensure in accordance with guidelines and other delegated tasks they have been approved to do... Delegates appropriate and approved tasks they have been approved to do..." The job description did not document what procedures and other tasks the paramedic was approved to do. The job description did not document what tasks the paramedic could delegate and to whom.

4. A hospital job description for Emergency Medical Technician I, had no documentation of job responsibilities in the hospital emergency department. The job description only addressed job responsibilities for patient care during pre-hospitalization.

5. On 06/28/12, Staff L was asked if paramedics and emergency medical technicians provided patient care in the emergency department. She stated they did. She was asked if the hospital had designated what tasks each care-giver was approved to do. She stated there was no such designation.

6. Staff L stated on 06/28/12 in the afternoon that the Medical Staff and the Governing Body had not approved what duties that Paramedics and EMT's were approved to perform on patients in the ED.