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The hospital failed to maintain an ongoing quality improvement program in that:

1) Nursing care plans were not monitored or evaluated as to content or compliance with hospital policy. This lack of care planning contributed to absence of nursing interventions and/or unrecognized changes in patient condition.

2) Eligibility of Allied Health Professional (AHP's) to provide emergency department services was not evaluated for compliance with the medical staff bylaws. Allowing these personnel to provide ED services was a potential for diminished quality of care.

Cross refer A0276.

Based on review of records, 3 of 3 Allied Health Professionals (AHP ' s) (Personnel #24, #25, and #28) had not been determined eligible to provide patient care in the Emergency Department (ED). The competency and performance of these AHP's were not evaluated by the Credentialing Committee; these AHP's were not recommended by medical staff, nor appointed by Governing Board to provide ED services.

Findings:

The Personnel file of Physician Assistant (PA) (Personnel #25) did not include training, experience, competencies, and/or privileges for providing service in the ED. His job description did not address provision of ED services. The Credentialing File showed he was not credentialed for years 2009 and 2010. Personnel #25 provided patient care to 81 patients in the ED from December 2009 through January 2010.

The privileges delineated for Family Nurse Practitioner (FNP) (Personnel #28) showed she had not been re-credentialed since February 2007. The only "Medical Protocols for Mid-Level Providers" signed by this FNP was dated 12/4/99, and did not address ED services. Personnel #28 provided patient care to 7 patients in the ED in December 2009.

The hospital's listing of credentialed AHP's showed FNP (Personnel #24) was not re-credentialed for 2010. Personnel #24 provided patient care to 18 patients in the ED in January 2010.

In an interview with Personnel #29, on the afternoon of 02/24/10, she was asked if the Personnel #24, #25 and #28 were re-credentialed in 2009 and/or 2010 to provide patient care. She stated, " No. "

The " bylaws of the Medical Staff of Comanche County Medical Center " Article VIII dated 08/2002 noted, " The delineation of an AHP ' s scope of practice shall be based upon the AHP Applicant ' s academic and clinical training, experience, judgment and demonstrated competence to provide patient care under the supervision and responsibility of a licensed physician ...are credentialed by the Medical Staff to assure appropriate education and experience ...may only engage in acts within the scope of practice specifically approved by the Board ...are credentialed on the recommendation of the Medical Staff and on the approval of the Board of Directors. " It goes on to state, " Each applicant shall be evaluated by the Credentials Committee ...shall recommend to the Medical Staff the scope of practice and/or clinical privileges ...recommendations of the Medical Staff shall be sent to the Board for final decision ...shall be for no more than 12 months ...reassignments shall be for a period of up to one year ... "

Based on review of records, and interviews, the nursing staff did not develop and keep current a nursing plan of care for each patient, which addresses the patient's needs, in that, 7 of 7 inpatients (Patients #20, #21, #22, #26, #27, #28, & #29), did not have updated or resolved care plans. Each care plan was initiated at admission; however no care plan was developed to demonstrate patient progress or deterioration, and care plan did not include nursing problems identified for each patient.

1) Patient # 20, age 84, admitted to Swing Bed status 02/19/10 with a diagnosis of CVA (cardiovascular accident), mental status changes. Her care plan was initiated on 02/19/10 for weakness, with a plan for physical therapy to increase strength. This patient was discharged 02/24/10.

2) Patient # 21, age 75, admitted to Swing Bed status 11/20/09 with a diagnosis of CVA (cardiovascular accident) on right side of her body and sepsis. Her care plan was initiated on 11/20/09 for weakness, with a plan for physical therapy to increase strength. However, sepsis was not addressed. This patient was discharged 11/25/09.

3) Patient #22, age 79, admitted 02/02/10 with a diagnosis of left lower lobe pneumonia and COPD (chronic obstructive pulmonary disease). Her care plan was initiated on admission for weakness and blood sugar monitoring (diabetic patient). On 02/07/10, this patient ' s respiratory condition worsened. The patient was discharged 02/09/10.

4) Patient #26, age 70, admitted 07/02/09 with a diagnosis of COPD and renal failure. His care plan was initiated on admission for electrolyte imbalance and renal failure. On 07/03/09 his respiratory condition progressively deteriorated and was subsequently intubated and transferred to another facility for a higher level of care.

5) Patient #27, age 74, admitted on 02/22/10 with acute blood loss anemia. His care plan was initiated 02/22/10 for anemia. However the care plan did not address that he had been receiving blood and had an EGD (Esophagogastroduodenoscopy) procedure.

6) Patient #28, age 50, admitted on 02/22/10 with SOB (shortness of breath), asthma, fever and coughing with a diagnosis of left lower lobe pneumonia. Her care plan was initiated on 02/22/10 for Dyspnea/SOB. She was discharged on 02/24/10.

7) Patient #29, age 32, admitted on 02/22/10 with nausea, vomiting and abdominal pain with a diagnosis of dehydration and hemataemesis (vomiting of blood). Her care plan was initiated on 02/22/10 for dehydration and intractable nausea and vomiting. She had an EGD performed 02/23/10 and was discharged home on 02/24/10.

The " Nursing Care Plans " policy number 000120, dated January 25, 2000 noted, " Care Plans will be initiated on every patient admitted to Acute Care ...The RN should revise the care plan as needed - resolve problems or add problems as the condition changes ...The care plan should ...be updated at all times ...show the patients progression or deterioration ... "

In an interview the afternoon of 02/23/10, the Director of Med-Surgical Floor (Personnel #6) was asked if the above patient care plans were updated and current to reflect changes in the patient conditions. She stated, " No. "

Texas Administrative Code, title 22, Part 11, Chapter 217, Rule ? 217.11 Standards of Nursing Practice (3) Standards Specific to Registered Nurses. " The registered nurse shall assist in the determination of healthcare needs of clients and shall:
(A) Utilize a systematic approach to provide individualized, goal-directed, nursing care by:
(i) performing comprehensive nursing assessments regarding the health status of the client;
(ii) making nursing diagnoses that serve as the basis for the strategy of care;
(iii) developing a plan of care based on the assessment and nursing diagnosis;
(iv) implementing nursing care; and
(v) evaluating the client's responses to nursing interventions "

Based on review of records, and interviews, the hospital failed to provide orientation and evaluation for 2 of 2 (RN #32 !) nonemployee licensed nurses who provided direct patient care and/or supervised nursing staff between 06/08/09 and 10/09/09.


Findings Included:

Monthly Medical-Surgical Staffing sheets showed:

RN #32 worked the 6 pm - 6 am shift on the medical surgical floor on 06/08/09, 06/10/09, 06/15/09, 06/16/09, 06/19/09, 06/20/09, 06/25/09, 06/26/09, 06/27/09, 06/30/09, 07/03/09, 07/04/09, 07/05/09, 07/08/09, 07/09/09, 07/13/09, 07/14/09, 07/17/09, & 07/18/09.

RN #33 worked the 6 pm - 6 am shift on the medical surgical floor on 07/13/09, 07/14/09, 07/17/09, 07/18/09, 07/19/09, 07/22/09, 07/23/09, 07/27/09, 07/28/09, 07/31/09, 08/01/09, 08/02/09, 08/04/09, 08/05/09, 08/06/09, 08/10/09, 08/11/09, 08/14/09, 08/15/09, 08/16/09, 08/19/09, 08/20/09, 08/24/09, 08/25/09, 08/28/09, 08/29/09, 08/30/09, 09/27/09, 09/30/09, 10/01/09, 10/05/09, 10/06/09, & 10/09/09.

In an interview with the CNO (Personnel #2) on the afternoon of 02/24/10, she was asked how nonemployee nurses were oriented or evaluated. She stated she had no system in place for either orientation or evaluation.

Hospital policy "Nursing Orientation" revised January 31, 2006 requires that " the hospital will provide a structured nursing orientation for new employees and agency personnel. "

Based on observation and interviews, the pharmacy did not ensure that drugs and biologicals were secured and/or locked appropriately in 2 of 2 areas (Operating Room and Emergency Department).

On tours the afternoon of 02/22/10, the surveyor observed the following unsecured drugs, which were stored and available for use by employees and/or nonemployees.

1) The Endoscopy Room, located in the non-sterile surgical area of the Operating Room (OR), had an unlocked anesthesia cart which contained:
- 18 bottles of Propofol 1% 20 milliliters (ml).
- 7 bottles of Propofol 1% 100 mls.

2) The Trauma Room, located in the Emergency Department (ED), had an unlocked drawer and cabinets which contained the following drugs:
- 1 bottle Nitroglycerin spray
- 5 bottles Lidocaine1% 10 mls.
- 4 bottles Sodium Bicarbonate 4.2% 5 mls.
- 1 bottle Xylocaine 2% 20 mls.
- 1 bottle Phentolamine 1 ml.
- 4 bottles Heparin 5,000 units 1 ml.
- 4 bottles Lovenox 100mg/ml 1 ml.
- 4 bottles Digoxin 0.5 mg/2 ml
- 6 bottles Epinephrine 1:1000
- 2 bottles Romazicon 0.1mg/1ml.
- 7 bottles Narcan 1 mg/ml
- 5 bottles Benadryl 1 mg
- 10 bottles Dexamethasone 1 mg
- 11 bottles Methylprednisolone 40 mg
- 3 bottles Lasix 40 mg
- 8 bottles Promethazine 25 mg
- 8 bottles Promethazine 50 mg
- 8 bottles Ketoralac 30 mg
- 8 bottles Ketoralac 60 mg
- 13 bottles Xopenex 1.25 mg/3 ml
- 3 bottles Xopenex 0.63 mg/3 ml
- 24 bottles Xopenex .031 mg/ml
- 19 vials Albuterol 3 mls
- 1 bottle Acetylcysteine 100 ml

In an interview the morning of 02/23/10, the certified registered nurse anesthetist (CRNA) (Personnel #26), was asked if he kept the anesthesia cart locked, and he said " No. " When asked if he locked up the Propofol, an anesthetic agent, when the operating rooms were closed, he said " No. "

In an interview the afternoon of 01/22/10, the Director of ED (Personnel #14), was asked if the medications in the trauma room of the ED are kept locked and secured. She stated, " No. "

In an interview the morning of 02/23/10, the Pharmacist (Personnel #30), was asked whether he or his staff checked the drugs on the anesthesia cart in the surgical area, or ensured that those drugs were kept secure and were locked for safety, he said " No. " When he was asked if he or his staff ensured that the drugs in the trauma room in the ED were kept locked and secure for safety, he said, " No. "

The " Pharmacy Department Policy " , last reviewed 07/16/09, did not address pharmacy oversight to ensure security of drugs used in the OR and ED.

Based on review of records and interviews, the surgical services had not maintained the OR (operating room) physician privileges roster, in that, the roster had not been kept current.

A review of the folder used as the OR physician privileges roster contained copies of individual physician specified privileges, and dated when they had been credentialed. Files contained within this roster included:
-Personnel #27, a physician whose surgical privileges were approved October 2005.
-Personnel #28, a nurse practitioner, whose privileges were approved February 2007, and did not include surgical privileges.

In an interview the morning of 02/23/10, the Director of Surgical Services (Personnel #10), confirmed that Personnel #28 was a physician who had not performed surgery in their facility in several years. She agreed that the OR roster was not current, and that it included staff (Personnel #28) who did not have surgical privileges. When asked how many physicians had privileges to perform surgeries in this facility, she said "she did not know."

A review of the credentialed medical staff roster noted:
-Personnel #27 was not listed as an active physician with current privileges at this facility.
-Personnel #28 was listed as an allied health professional, and had not been re-credentialed.

In an interview the morning of 02/24/10, when asked if Personnel #27 was an active physician with current surgical privileges, the Medical Credentialing Specialist (Personnel # 29), said "no." She also confirmed that the allied health professional (Personnel #28) had not been recently re-credentialed and did not have surgical privileges.

Based on review of records and interview, the hospital Performance Improvement Program failed to identify the following opportunities for improvement in delivery of nursing services and emergency department (ED) services:
1) Nursing Care Plans were not updated to reflect changes in the patients' condition.
2) Allied Health Professionals (AHP's) were not determined eligible to provide ED services.

Findings:

1) The quality improvement data related to care planning was limited to the admission diagnosis. In an interview the afternoon of 02/23/10, the Director of Medical Surgical Floor (Personnel #6) was asked if the Nursing Department monitored the Nursing Care Plans for updates and revisions to reflect changes in the patients' condition in the Performance Improvement Program. She stated, " No. " Cross refer A0396

2) Quality improvement data did not include monitoring for qualifications or job performance of AHP's who provided ED services. In an interview the afternoon of 02/24/10, the Medical Credentialing person (Personnel #29) was asked if AHP ' s were currently credentialed for providing patient care. She stated, " No. " Cross refer A0045