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Based on review of documentation and interviews with facility staff, the facility failed to clearly delineate responsibilities for patient care as the facility procedure for bowel management system rectal tube insertion did not specify what staff could perform the procedure, contraindications to the procedure, or if a physician order was required. Registered Nurse (staff #1) placed a bowel management system rectal tube in patient #1 without a physician's order which resulted in a vaginal vault laceration in patient #1.

The findings were:
The facility procedure entitled "Mosby Skills - Bowel Management System (BMS)" with a revision date of September 2010 was reviewed on 10/22/12. The procedure did not specify what staff could perform the procedure, contraindications to the procedure or if a physician order was required for insertion of the bowel management system rectal tube.

The medical record of patient #1 was reviewed on 10/22/12. The ER (Emergency Room) nurses' note dated 8/17/12 1555 by registered nurse staff #1 reflected in part "Pt (patient) with full yellow liquid diaper. Cleaned pt and placed (size) 16 Foley cath (catheter) with sterile technique done. Rectal tube placed and filled reservoir with 45 cc (cubic centimeters) H2O (water). At 8/17/12 1900 "Report called to ICU nurse. Pt with no changes. NAD (no apparent distress) noted."

The Admission Physician Orders dated 8/17/12 6:35 pm written by physician staff #2 reflected in part "Insert Indwelling Urinary Catheter." The record did not contain an order for a rectal tube.

A GYN Progress Note dated 8/18/12 1200 by physician staff #3 reflected in part "In ER was noted to have profuse diarrhea. Rectal tube was inadvertently placed in vagina. On arrival to ICU, was noted to have vaginal bleeding and clots ....Vaginal vault laceration secondary to placement of rectal tube."

Staff #1 was interviewed on 10/22/12 at 12:50 pm and was asked if there was a physician's order for the rectal tube. Staff #1 stated it was a nursing intervention and no order was needed. Staff #1 stated ICU nurses at the facility put in rectal tubes as indicated without physician orders. Staff #1's personnel file was reviewed on 10/22/12 and reflected a previous assignment in the ICU.

The interim Chief Nursing Officer, staff #4, was interviewed on 10/22/12 at 2:10 pm. Staff #4 was asked what the facility policy was regarding if a physician order was required for a nurse to insert a rectal tube. Staff #4 stated a written policy could not be found that showed that either a physician order was required or was not required for the procedure. Staff #4 stated the practice in ICU was that nurses inserted rectal tubes using their nursing judgment without a physician order. Staff #4 also stated that invasive procedures involving inserting something in a body cavity usually required a physician order.

Based on review of documentation and interviews with facility staff, the facility failed to ensure that verbal orders were authenticated within 48 hours as 8 of 21 verbal orders in the medical record of patient #1 were not authenticated within 48 hours.

The findings were:
The medical record of patient #1 was reviewed on 10/22/12. The record of patient #1 contained 21 verbal physician orders. 8 of the 21 verbal physician orders were not authenticated within 48 hours.

In an interview with staff #5 on 10/22/12 at 1:45 pm, staff #5 confirmed there were verbal orders in the record that were not authenticated within 48 hours.