HospitalInspections.org

Based on record review and interview, the Governing Body failed to ensure quality of care while allowing paramedics to function outside their scope of practice while providing patient care in a Hospital Setting, in that

A. 6 of 6 paramedics were allowed to perform nursing tasks (not within the scope of practice for Paramedics in a Hospital setting) including: peripheral IV placement, defibrillation and pacing, patient restraints, intraosseous infusion, care of a trach patient including suctioning of the trach, central venous pressure monitoring.

B. On 6/6/2018, the hospital was not able to staff their inpatient unit with nurses for Patient #24.

C. 1 of 1 (agency) non-employee licensed nurse (Personnel #52) worked shifts on 2/2/18 and 3/5/18 and did not have documented hospital competencies or evaluation of the nursing care.


Cross Reference to A0144 and A0386

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


A. 6 of 6 paramedics were allowed to perform nursing tasks (not within the scope of practice for Paramedics in a Hospital setting) including: peripheral IV placement, defibrillation and pacing, patient restraints, intraosseous infusion, care of a trach patient including suctioning of the trach, central venous pressure monitoring.


B. On 6/6/2018, the hospital was not able to staff their inpatient unit with nurses for Patient #24.


C. 1 of 1 agency non-employee licensed nurse worked shifts on 2/22/18 and 3/5/18 without documented competencies or evaluation of nursing care.


Cross Reference Tag 386 and Tag 399

Based on observation, record review, and interview, the facility failed to ensure the patient rights to include the ability to submit a complaint to the (HHSC) Health and Human Services Commission/(DSHS) Department State Health Services was posted, in that, the right's posting in the emergency room lobby contained (888-973-0011) the wrong phone number for HHSC.

There were 4083 emergency room (ER) patients for 2018.

Findings included

During a tour on 6/5/18 at 11:30 AM, Personnel #1 accompanied the surveyor to the ER lobby. The patient's rights posting was reviewed and the wrong number was present on the english posting.

The patient's admission packet included a Patient Right's Handout. The hand out contained the wrong phone number for HHSC (888-973-0011).

The correct phone number is 888-973-0022.

During an interview on 6/5/18 at 11:30 AM, Personnel #1 was informed of the above findings. Personnel #1 reviewed the posting and confirmed the finding.

The hospital's 3/06/15, last revised, "Patient Rights and Responsibilities" policy required, the patient may lodge a complaint with the State Department of Health..."

Based on record review and interview, the facility failed to ensure each patient was informed of the patient's right to submit a complaint to the (HHSC) Health and Human Services Commission/(DSHS) Department State Health Services, in that, the patient right's handout contained (888-973-0011) the wrong phone number for HHSC.

There were 27 in-patients and 4083 emergency room (ER) patients for 2018.

Findings included

The patient's admission packet included a Patient Right's Handout. The hand out contained the wrong phone number for HHSC (888-973-0011).

The correct phone number is 888-973-0022.

During an interview on 6/5/18 at 11:30 AM, Personnel #1 was informed of the above findings. Personnel #1 reviewed the hand out and confirmed the finding.

The hospital's 3/06/15, last revised, "Patient Rights and Responsibilities" policy required, the patient may lodge a complaint with the State Department of Health..."

Based on record review and interview, the hospital failed to have an effective plan for providing adequate nursing staff for the care of inpatients, in that,

1. 7 of 7 Paramedics (Personnel #44, #45, #46, #47, #48, #49, and #50) were allowed to perform nursing tasks in the emergency room (not within the scope of practice for Paramedics in a hospital setting.)

2. On 6/6/2018, the hospital was not able to staff their inpatient unit with nurses for Patient #52


Findings included:

A. During a tour of the emergency room on 6/6/2018 at approximately 11:00 AM, this surveyor was observing patient care in the ER and observed Personnel #44 (Paramedic/EMT) triaging patient as they presented to the ER. Personnel #44 completed initial patient intake, including chief complaints and reported the findings to the nurse before placing the patient in a room.

The hospital 6/7/2018 "Personnel list" included 7 Emergency Medical Technician (EMT's)/Paramedics, (Personnel #44, #45, #46, #47, #48, #49, and #50), who worked in the Emergency Department.

The hospital's "Paramedic Skills Checklist" including nursing skills of :

"peripheral IV catheter insertion...intraosseous infusion...central venous pressure monitoring...Lab verification - Point of care (validated by lab personnel)...performs NG/OG tube insertion and removal...Physician orders, transcribes...care of tracheostomy patient, including ET (endotracheal) tube suctioning...performs chest tube set ups and manages...crutch fitting and teaching...performs symptoms management at end of life...working with suicidal patients...capnography...5 level triage, emergency severity index...and adult sexual assault survivors in the ED..."


Personnel (Paramedic)#44's skills checklist reflected competencies completed on 4/1/2014, 8/14/14, 4/20/15, peripheral IV catheter insertion, performs defibrillation and pacing set up and performs in presence of physician, ED (emergency department) documentation completes, notifies the RN of abnormal findings or changes in patient status, performs symptoms management at end of life, restraints, stroke attestation; working with suicidal patients; capnography; 5 level triage; emergency severity index.

Personnel (Paramedic) #45's skill checklist reflected competencies completed on 5/27/16. Adult sexual assault survivors in the ED.

Personnel (Paramedic) #46 skills checklist reflected competencies completed on 9/14/14 and 8/17/16. Intraosseous infusion, central venous pressure monitoring.

Personnel (Paramedic)#47 skills checklist reflected competencies completed on 5/5/16.

Personnel (Paramedic) #48 skills checklist reflected competencies completed on 8/8/15. Lab verification - Point of care (validated by lab personnel); Performs NG/OG tube insertion and removal; Physicians orders, transcribes; Care of tracheostomy patient, including ET (endotracheal) tube suctioning performs; Chest tube set up and manages; crutch fitting and teaching;

Personnel (Paramedic) #49 skills checklist reflected competencies completed on 12/14/17.


The hospital's EMT/ER Tech/Paramedic job description reflected, the ED Technician assists with basic patient care based on individual patient needs within his/her scope of practice under direct supervision of the registered nurse. This position maintains effective working relationships with all customers including patient/families, physicians, employees, volunteers and vendors...Provides direct and indirect patient care under the direction of a registered nurse and/or licensed vocational nurse...Maintains regulatory agency requirements, nursing and hospital policies, procedures and standards....performs all aspects of patient care in an environment that optimizes patient safety.


Licenses and Certification: Certification as an EMT, Paramedic required, or completion of the first semester of an accredited ADN or BSN nursing school to include a Nursing Fundamentals course, Current BLS required."


Review of the Medical Staff Bylaws, Rules and Regulations on 6/5/2018, revealed, no documentation of Paramedic duties or guidelines for Paramedics working in the ER. There was no documentation of compliance with TMB (Texas Medical Board ) Title 22 Part 9 Rule 197.7 Physician Supervision of Emergency Medical Technician Paramedic or Licensed Paramedic Care Provided in a Health Care Facility Setting in regards to Paramedic duties or guidelines for Paramedics working in the ER.


Review of the Governing Body Minutes and Medical Executive Staff minutes (6/5/2018) for the past year, revealed, no documentation of care measures to monitor care provided by the paramedics was within their scope of practice for a hospital ED setting.


Review of the Governing Body Minutes and Medical Executive Staff (on 6/5/2018) for the past year, revealed, no documentation in the minutes that discussed Paramedics and their duties in the ER.


On 6/6/2018, at approximately 11:00 AM, surveyor was observing patient care in the ER and observed Personnel #44 (Paramedic/EMT) triaging patients as they presented to the ER. Personnel #44 completed initial patient intake, including chief complaints and reported the findings to the nurse before placing the patient in a room.


During the tour of the ER on 6/6/2018, an interview with Personnel #11 was conducted. Personnel #11 was asked what the Paramedic/EMT's duties were in the ER. Personnel # 11 stated hat the paramedics do everything a nurse does except administer medication/push medications.


During an interview on 6/5/2018 at 11:00 AM, Personnel #2 was asked how the paramedics are functioning. Personnel #2 stated, "They are an extra pair of hands. They start (intravenous catheters) IV's, DC IV'S, take patients to the car."


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)


(a) The following words and terms, when used in this section, shall have the following meanings, unless the context clearly indicates otherwise.

(1) Advanced life support--Health care provided to sustain life in an emergency, life-threatening situation. The term includes the initiation of intravenous therapy, endotracheal or esophageal intubation, electrical cardiac defibrillation or cardioversion, and drug therapy procedures.

(2) 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.

(3) Emergency medical technician-paramedic (EMT-P) or licensed paramedic (LP)--An individual who is certified by the Department of State Health Services (DSHS) as minimally proficient to provide advanced life support that includes initiation and maintenance of certain procedures under a physician's supervision, including intravenous therapy, endotracheal or esophageal intubation or both, electrical cardiac defibrillation or cardioversion, and drug therapy.

(4) Protocols--Written instructions providing EMT-Ps or LPs with a standardized approach to commonly encountered problems in a health care facility-based setting, typically in regard to patient care.

(5) Standing delegation orders--Instructions or orders provided by a supervising physician to EMT-Ps or LPs, directing them to perform certain medical care, as allowed by law.

(b) Notwithstanding other law, 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.

(c) 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.

(d) 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.

(e) 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.


Source Note: The provisions of this §197.7 adopted to be effective April 3, 2016, 41 TexReg 2315

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.



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

(a) Tasks Which are Most Commonly Delegated. By way of example, and not in limitation, the following nursing tasks are ones that are most commonly the type of tasks within the scope of sound professional nursing practice to be considered for delegation, regardless of the setting, provided the delegation is in compliance with §224.6 of this title (relating to General Criteria for Delegation) and the level of supervision required is determined by the RN in accordance with §224.7 of this title (relating to Supervision):

(2) the following are nursing tasks that are not usually within the scope of sound professional nursing judgment to delegate and may be delegated only in accordance with, §224.6 of this title and paragraph (1) of this subsection. These types of tasks include:

(A) sterile procedures--those procedures involving a wound or an anatomical site which could potentially become infected;

(B) non-sterile procedures, such as dressing or cleansing penetrating wounds and deep burns;

(C) invasive procedures--inserting tubes in a body cavity or instilling or inserting substances into an indwelling tube; and

(D) care of broken skin other than minor abrasions or cuts generally classified as requiring only first aid treatment.

(c) 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:

(1) physical, psychological, and social assessment which requires professional nursing judgment, intervention, referral, or follow-up;

(2) formulation of the nursing care plan and evaluation of the client's response to the care rendered;

(3) specific tasks involved in the implementation of the care plan which require professional nursing judgment or intervention;

(4) the responsibility and accountability for client health teaching and health counseling which promotes client education and involves the client's significant others in accomplishing health goals; and

(5) 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).


Patient #24 was admitted to the ER on 6/6/2018 during the early morning hours. The patient was kept in the ER until nursing staff could be called in to move the patient to the Medical/Surgical nursing unit. Personnel #3 advised that he had called on-call nurse to come in to care for this patient in the Medical/Surgical nursing unit. Personnel #3 returned to advise that he called 5 on-call nurses to report to duty at the hospital and four of five nurses refused to come into work. One RN (Personnel #53) reported to work to care for the patient. The patient was kept in the emergency room for back up nursing coverage.


An interview with Personnel #3 on the morning of 6/6/2018, Personnel #3 stated that when there are no inpatients, they (hospital) have been placing nurses on-call to come in if patients are admitted. Personnel #3 states that it has been getting harder to get nurses to come in when they are on-call and called in to take care of a patient that is admitted. Personnel #3 stated that they cannot pay nurses to be in-house when they do not have patients. When this (not able to get an RN to come staff the inpatient unit) happens, we keep the patient in the emergency room so we have RN back-up for the RN caring for the inpatient in the emergency room.

Based on record review and interview, the hospital failed to have an effective plan for providing adequate nursing staff for the care of inpatients, in that,

1. 6 of 6 Paramedics (Personnel #44, #45, #46, #47, #48 , #49, and #50) were allowed to perform nursing tasks in the emergency room (nt within the scope of practice for Paramedics in a hospital setting).

2. On 6/6/2018, the hospital was not able to staff their inpatient unit with nurses for Patient #24.


Findings included:


A. During a tour of the emergency room on 6/6/2018, at approximately 11:00 AM, surveyor was observing patient care in the ER and observed Personnel #44 (Paramedic/EMT) triaging patient as they presented to the ER. Personnel #44 completed initial patient intake, including chief complaints and reported the findings to the nurse before placing the patient in a room.

The hospital 6/7/2018"Personnel list" included 7 Emergency Medical Technician (EMT's)/Paramedics (Personnel #44, #45, #46, #47, #48, #49, and #50) who worked in the Emergency Department.


The hospital's "Paramedic Skills Checklist" including nursing skills of :

"peripheral IV catheter insertion...intraosseous infusion...central venous pressure monitoring...Lab verification - Point of care (validated by lab personnel)...performs NG/OG tube insertion and removal...Physician ordeers, transcribes...care of tracheostomy patient, including ET (endotracheal) tube suctioning...performs chest tube set ups and manages...crutch fitting and teaching...performs symptoms management at end of life...working with suicidal patients...capnography...5 level triage, emergency severity index...and adult sexual assault survivors in the ED..."


Personnel (Paramedic)#44's skills checklist reflected competencies completed on 4/1/2014, 8/14/14, 4/20/15, peripheral IV catheter insertion, performs defibrillation and pacing set up and performs in presence of physician, ED (emergency department) documentation completes, notifies the RN of abnormal findings or changes in patient status, performs symptoms management at end of life, restraints, stroke attestation; working with suicidal patients; capnography; 5 level triage; emergency severity index.

Personnel (Paramedic) #45's skill checklist reflected competencies completed on 5/27/16. Adult sexual assault survivors in the ED.

Personnel (Paramedic) #46 skills checklist reflected competencies completed on 9/14/14 and 8/17/16. Intraosseous infusion, central venous pressure monitoring.

Personnel (Paramedic)#47 skills checklist reflected competencies completed on 5/5/16.

Personnel (Paramedic) #48 skills checklist reflected competencies completed on 8/8/15. Lab verification - Point of care (validated by lab personnel); Performs NG/OG tube insertion and removal; Physicians orders, transcribes; Care of tracheostomy patient, including ET (endotracheal) tube suctioning performs; Chest tube set up and manages; crutch fitting and teaching;

Personnel (Paramedic) #49 skills checklist reflected competencies completed on 12/14/17.


The hospital's EMT/ER Tech/Paramedic job description reflected, The ED Technician assists with basic patient care based on individual patient needs within his/her scope of practice under direct supervision of the registered nurse. This position maintains effective working relationships with all customers including patient/families, physicians, employees, volunteers and vendors...Provides direct and indirect patient care under the direction of a registered nurse and/or licensed vocational nurse...Maintains regulatory agency requirements, nursing and hospital policies, procedures and standards....performs all aspects of patient care in an environment that optimizes patient safety.
Licenses and Certification: Certification as an EMT, Paramedic required, or completion of the first semester of an accredited ADN or BSN nursing school to include a Nursing Fundamentals course, Current BLS required."


Review of the Medical Staff Bylaws, Rules and Regulations on 6/5/2018, revealed no documentation of Paramedic duties or guidelines for Paramedics working in the ER. There was no documentation of compliance with TMB (Texas Medical Board ) Title 22 Part 9 Rule 197.7 Physician Supervision of Emergency Medical Technician Paramedic or Licensed Paramedic Care Provided in a Health Care Facility Setting in regards to Paramedic duties or suidelines for Paramedics working in the ER.


Review of the Governing Body Minutes and Medical Executive Staff minutes ( 6/5/2018) for the past year, rvealed no documentation of care measures to monitor care provided by the paramedics was within their scope of practice for a hospital ED setting.


Review of the Governing Body Minutes and Medical Executive Staff (6/5/2018) for the past year, revealed no documentation in the minutes that discussed Paramedics and their duties in the ER.


On 6/6/2018, at approximately 11:00 AM, surveyor was observing patient care in the ER and observed Personnel #44 (Paramedic/EMT) triaging patients as they presented to the ER. Personnel #44 completed initial patient intake, including chief complaints and reported the findings to the nurse before placing the patient in a room.


During the tour of the ER on 6/6/2018, an interview with Personnel #11 was conducted. Personnel #11 was asked what the Paramedic/EMT's duties were in the ER. Personnel # 11 went on to say that the paramedics do everything a nurse does except administer medication/push medications.


During an interview on 6/5/2018 at 11:00 AM, Personnel #2 was asked how the paramedics are functioning. Personnel #2 stated, "They are an extra pair of hands. They start (intravenous catheters) IV's, DC IV'S, take patients to the car."


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)

(a) The following words and terms, when used in this section, shall have the following meanings, unless the context clearly indicates otherwise.

(1) Advanced life support--Health care provided to sustain life in an emergency, life-threatening situation. The term includes the initiation of intravenous therapy, endotracheal or esophageal intubation, electrical cardiac defibrillation or cardioversion, and drug therapy procedures.

(2) 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.

(3) Emergency medical technician-paramedic (EMT-P) or licensed paramedic (LP)--An individual who is certified by the Department of State Health Services (DSHS) as minimally proficient to provide advanced life support that includes initiation and maintenance of certain procedures under a physician's supervision, including intravenous therapy, endotracheal or esophageal intubation or both, electrical cardiac defibrillation or cardioversion, and drug therapy.

(4) Protocols--Written instructions providing EMT-Ps or LPs with a standardized approach to commonly encountered problems in a health care facility-based setting, typically in regard to patient care.

(5) Standing delegation orders--Instructions or orders provided by a supervising physician to EMT-Ps or LPs, directing them to perform certain medical care, as allowed by law.

(b) Notwithstanding other law, 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.

(c) 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.

(d) 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.

(e) 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.


Source Note: The provisions of this §197.7 adopted to be effective April 3, 2016, 41 TexReg 2315

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.


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

(a) Tasks Which are Most Commonly Delegated. By way of example, and not in limitation, the following nursing tasks are ones that are most commonly the type of tasks within the scope of sound professional nursing practice to be considered for delegation, regardless of the setting, provided the delegation is in compliance with §224.6 of this title (relating to General Criteria for Delegation) and the level of supervision required is determined by the RN in accordance with §224.7 of this title (relating to Supervision):

(2) the following are nursing tasks that are not usually within the scope of sound professional nursing judgment to delegate and may be delegated only in accordance with, §224.6 of this title and paragraph (1) of this subsection. These types of tasks include:

(A) sterile procedures--those procedures involving a wound or an anatomical site which could potentially become infected;

(B) non-sterile procedures, such as dressing or cleansing penetrating wounds and deep burns;

(C) invasive procedures--inserting tubes in a body cavity or instilling or inserting substances into an indwelling tube; and

(D) care of broken skin other than minor abrasions or cuts generally classified as requiring only first aid treatment.

(c) 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:

(1) physical, psychological, and social assessment which requires professional nursing judgment, intervention, referral, or follow-up;

(2) formulation of the nursing care plan and evaluation of the client's response to the care rendered;

(3) specific tasks involved in the implementation of the care plan which require professional nursing judgment or intervention;

(4) the responsibility and accountability for client health teaching and health counseling which promotes client education and involves the client's significant others in accomplishing health goals; and

(5) 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).


Patient #24 was admitted to the ER on 6/6/2018 during the early morning hours. The patient was kept in the ER until nursing staff could be called in to move the patient to the Medical/Surgical nursing unit. Personnel #3 advised that he had called on call nurses to come in to care for this patient in the Medical/Surgical nursing unit. Personnel #3 returned to advise that he called 5 on call nurses to report to duty at the hospital and four of five nurses refused to come into work. One RN (Personnel #53) reported to work to care for the patient. The patient was kept in the emergency room for back up nursing coverage.


An interview with Personnel #3 on the morning of 6/6/2018, Personnel #3 stated that when there are no inpatients, they (hospital) have been placing nurses on-call to come in if patients are admitted. Personnel #3 states that it has been getting harder to get nurses to come in when they are on-call and called in to take care of a patient that is admitted. Personnel #3 stated that they cannot pay nurses to be in-house when they do not have patients. When this (not able to get an RN to come staff the inpatient unit) happens, we keep the patient in the emergency room so we have RN back-up for the RN caring for the inpatient in the emergency room.

Based on record review and interview, the hospital failed to assure that non-employee licensed nurses who are working in the hospital had competencies and evaluation of the clinical activities when they are working in the hospital, in that
1 of 1 agency non-employee licensed nurse worked shifts on 2/22/18 and 3/5/18 without documented competencies or evaluation of nursing care.

Findings include:

Review of the personnel file of Personnel #52 on 6/4/2018, the personnel file did not document any evaluation of competencies of nursing tasks and did not document an evaluation of the nursing care provided on the days that she worked at the hospital.

"Staffing Plan/Staffing Effectiveness" policy (last revised 3/6/2015) required, "...orientation, competency and expertise are documented...nursing assignments are congruent with the documented competency ..."

An interview with Personnel #3 on 6/6/2018, Personnel #3 stated that he did not find a competency check list or an evaluation of the care provided by the agency nurse on the two days that she worked as an OR (operating room) nurse in the hospital.

Based on observation, interview, and record review, the hospital failed to ensure the dietary department requirements were in compliance in that the following was observed during the survey on 6/07/18.

1) 3 of 3 Hand sink's water temperatures were not maintained at least 100 degrees Fahrenheit.

2) Cleanliness issues were observed on the flat top grill.

3) A wet mop was observed in the janitor's closet resting upside down with the wet mop head against the wall.


Findings Included:

During a tour of the hospital's kitchen on the morning of 6/07/18 the following was observed:

1) Water temperatures were identified to be cool in the 3 hand sinks in the kitchen. Personnel #13 stated there were 3 hand sinks in the kitchen area. In all 3 hand sinks, the hot water valve was turned on for 3 minutes. The water remained cool to the touch. Personnel #13 confirmed the findings.

2) The flat top grill was observed to have grease, grime and food debris on the left side. On the right side grease and food debris was scraped from the grill top and left in front of the grill. Tortillas were being warmed on the right side. Personnel #51 said he had not used the left side of the grill top in over a week. He said it wasn't working.

3) A wet mop was observed in the janitor's closet resting upside down with the wet mop head against the wall. Personnel #13 placed the wet mop on the wall mounted holder.

Based on interview and record review, the hospital failed to ensure the hospital's UR committee had members who did not have a direct financial interest in the hospital, in that Personnel #6 was a member.

Findings included:

On 6/06/18 at 3:15 PM Personnel #1 was asked to provide a list of the UR committee members. Personnel #1 was asked by the surveyor if any of the members had a direct financial interest in the hospital. She said Personnel #6 did.

A review of the UR committee's meeting minutes for May, 2018 revealed Personnel #6 took part in the meeting via "Teleconference."

A review of the hospital's Utilization Plan policy with a review date of 5/15/18 reflected, "...The committee reviews may not be conducted by any individual who has a direct financial interest in the hospital or was professionally involved in the care of the patient who case is being reviewed..."

Based on record review and interview, the hospital failed to have an effective plan for providing adequate nursing staff for the care of inpatients, in that,

1.6 of 6 Paramedics (Personnel #44, #45, #46, #47, #48, #49, and #50) were allowed to perform nursing tasks in the emergency room (above the hospital scope of practice for Paramedics.

2. On 6/6/2018, the hospital was not able to staff their inpatient unit with nurses for Patient #24.


Findings included:

A. During a tour of the emergency room on 6/6/2018, at approximately 11:00 AM, surveyor was observing patient care in the ER and observed Personnel #44 (Paramedic/EMT) triaging patient as they presented to the ER. Personnel #44 completed initial patient intake, including chief complaints and reported the findings to the nurse before placing the patient in a room.


The hospital 6/7/2018"Personnel list" included 7 Emergency Medical Technician (EMT's)/Paramedics (Personnel #44, #45, #46, #47, #48, #49, and #50) who worked in the Emergency Department.


The hospital's "Paramedic Skills Checklist" including nursing skills of :

"peripheral IV catheter insertion...intraosseous infusion...central venous pressure monitoring...Lab verification - Point of care (validated by lab personnel)...performs NG/OG tube insertion and removal...Physician orders, transcribes...care of tracheostomy patient, including ET (endotracheal) tube suctioning...performs chest tube set ups and manages...crutch fitting and teaching...performs symptoms management at end of life...working with suicidal patients...capnography...5 level triage, emergency severity index...and adult sexual assault survivors in the ED..."


Personnel (Paramedic)#44's skills checklist reflected competencies completed on 4/1/2014, 8/14/14, 4/20/15, peripheral IV catheter insertion, performs defibrillation and pacing set up and performs in presence of physician, ED (emergency department) documentation completes, notifies the RN of abnormal findings or changes in patient status, performs symptoms management at end of life, restraints, stroke attestation; working with suicidal patients; capnography; 5 level triage; emergency severity index.

Personnel (Paramedic) #45's skill checklist reflected competencies completed on 5/27/16. Adult sexual assault survivors in the ED.

Personnel (Paramedic) #46 skills checklist reflected competencies completed on 9/14/14 and 8/17/16. Intraosseous infusion, central venous pressure monitoring.

Personnel (Paramedic)#47 skills checklist reflected competencies completed on 5/5/16.

Personnel (Paramedic) #48 skills checklist reflected competencies completed on 8/8/15. Lab verification - Point of care (validated by lab personnel); Performs NG/OG tube insertion and removal; Physicians orders, transcribes; Care of tracheostomy patient, including ET (endotracheal) tube suctioning performs; Chest tube set up and manages; crutch fitting and teaching;

Personnel (Paramedic) #49 skills checklist reflected competencies completed on 12/14/17.


The hospital's EMT/ER Tech/Paramedic job description reflected, The ED Technician assists with basic patient care based on individual patient needs within his/her scope of practice under direct supervision of the registered nurse. This position maintains effective working relationships with all customers including patient/families, physicians, employees, volunteers and vendors...Provides direct and indirect patient care under the direction of a registered nurse and/or licensed vocational nurse...Maintains regulatory agency requirements, nursing and hospital policies, procedures and standards....performs all aspects of patient care in an environment that optimizes patient safety.

Licenses and Certification: Certification as an EMT, Paramedic required, or completion of the first semester of an accredited ADN or BSN nursing school to include a Nursing Fundamentals course, Current BLS required."


Review of the Medical Staff Bylaws, Rules and Regulations on 6/5/2018, revealed no documentation of Paramedic duties or guidelines for Paramedics working in the ER. There was no documentation of compliance with TMB (Texas Medical Board ) Title 22 Part 9 Rule 197.7 Physician Supervision of Emergency Medical Technician Paramedic or Licensed Paramedic Care Provided in a Health Care Facility Setting in regards to Paramedic duties or guidelines for Paramedics working in the ER.


Review of the Governing Body Minutes and Medical Executive Staff minutes (6/5/2018) for the past year, revealed no documentation of care measures to monitor care provided by the paramedics was within their scope of practice for a hospital ED setting.


Review of the Governing Body Minutes and Medical Executive Staff (on 6/5/2018) for the past year, revealed no documentation in the minutes that discussed Paramedics and their duties in the ER.


On 6/6/2018, at approximately 11:00 AM, surveyor was observing patient care in the ER and observed Personnel #44 (Paramedic/EMT) triaging patients as they presented to the ER. Personnel #44 completed initial patient intake, including chief complaints and reported the findings to the nurse before placing the patient in a room.


During the tour of the ER on 6/6/2018, an interview with Personnel #11 was conducted. Personnel #11 was asked what the Paramedic/EMT's duties were in the ER. Personnel # 11 stated that the paramedics do everything a nurse does except administer medication/push medications.


During an interview on 6/5/2018 at 11:00 AM, Personnel #2 was asked how the paramedics are functioning. Personnel #2 stated, "They are an extra pair of hands. They start (intravenous catheters) IV's, DC IV'S, take patients to the car."



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)

(a) The following words and terms, when used in this section, shall have the following meanings, unless the context clearly indicates otherwise.

(1) Advanced life support--Health care provided to sustain life in an emergency, life-threatening situation. The term includes the initiation of intravenous therapy, endotracheal or esophageal intubation, electrical cardiac defibrillation or cardioversion, and drug therapy procedures.

(2) 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.

(3) Emergency medical technician-paramedic (EMT-P) or licensed paramedic (LP)--An individual who is certified by the Department of State Health Services (DSHS) as minimally proficient to provide advanced life support that includes initiation and maintenance of certain procedures under a physician's supervision, including intravenous therapy, endotracheal or esophageal intubation or both, electrical cardiac defibrillation or cardioversion, and drug therapy.

(4) Protocols--Written instructions providing EMT-Ps or LPs with a standardized approach to commonly encountered problems in a health care facility-based setting, typically in regard to patient care.

(5) Standing delegation orders--Instructions or orders provided by a supervising physician to EMT-Ps or LPs, directing them to perform certain medical care, as allowed by law.

(b) Notwithstanding other law, 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.

(c) 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.

(d) 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.

(e) 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.

Source Note: The provisions of this §197.7 adopted to be effective April 3, 2016, 41 TexReg 2315

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.


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

(a) Tasks Which are Most Commonly Delegated. By way of example, and not in limitation, the following nursing tasks are ones that are most commonly the type of tasks within the scope of sound professional nursing practice to be considered for delegation, regardless of the setting, provided the delegation is in compliance with §224.6 of this title (relating to General Criteria for Delegation) and the level of supervision required is determined by the RN in accordance with §224.7 of this title (relating to Supervision):

(2) the following are nursing tasks that are not usually within the scope of sound professional nursing judgment to delegate and may be delegated only in accordance with, §224.6 of this title and paragraph (1) of this subsection. These types of tasks include:

(A) sterile procedures--those procedures involving a wound or an anatomical site which could potentially become infected;

(B) non-sterile procedures, such as dressing or cleansing penetrating wounds and deep burns;

(C) invasive procedures--inserting tubes in a body cavity or instilling or inserting substances into an indwelling tube; and

(D) care of broken skin other than minor abrasions or cuts generally classified as requiring only first aid treatment.

(c) 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:

(1) physical, psychological, and social assessment which requires professional nursing judgment, intervention, referral, or follow-up;

(2) formulation of the nursing care plan and evaluation of the client's response to the care rendered;

(3) specific tasks involved in the implementation of the care plan which require professional nursing judgment or intervention;

(4) the responsibility and accountability for client health teaching and health counseling which promotes client education and involves the client's significant others in accomplishing health goals; and

(5) 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).


Patient #24 was admitted to the ER on 6/6/2018 during the early morning hours. The patient was kept in the ER until nursing staff could be called in to move the patient to the Medical/Surgical nursing unit. Personnel #3 advised that he had called on call nurses to come in to care for this patient in the Medical/Surgical nursing unit. Personnel #3 returned to advise that he called 5 on call nurses to report to duty at the hospital and four of five nurses refused to come into work. One RN (Personnel #53) reported to work to care for the patient. The patient was kept in the emergency room for back up nursing coverage.


An interview with Personnel #3 on the morning of 6/6/2018, Personnel #3 stated that when there are no inpatients, they (hospital) have been placing nurses on-call to come in if patients are admitted. Personnel #3 states that it has been getting harder to get nurses to come in when they are on-call and called in to take care of a patient that is admitted. Personnel #3 stated that they cannot pay nurses to be in-house when they do not have patients. When this (not able to get an RN to come staff the inpatient unit) happens, we keep the patient in the emergency room so we have RN back-up for the RN caring for the inpatient in the emergency room.