Rivers Health

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 38282 Based on document review, medical record review, and staff interview, the Director of Nursing failed to supervise the clinical staff by delegating the insertion of a Foley catheter to nursing assistants (NA), which is out of their scope of practice, for two (2) patients (#3 and #4). Findings include: A review of the “Criteria for Determining Scope of Practice for Licensed Nurses and Guidelines for Determining Acts That May Be Delegated or Assigned by Licensed Nurses;” revised: 03/23/23; was reviewed, and stated in part: “Nursing practice assigned to unlicensed assistive personnel is limited to performance of the basic nursing care services, such as taking vital signs, providing personal hygiene, comfort, nutrition, ambulation and environmental safety and protection. Unlicensed workers are PROHIBITED from performing any licensed nursing function that is specifically defined for licensed nurses in the nursing practice acts or rules of the Boards of Nursing, except as specifically provided in West Virginia Code and Rules for AMAPs, School Nurses, Dialysis techs, EMS, etc ...” A review of the medical records for Patient #3 revealed a Foley catheter was inserted on 04/22/25 at 10:50 p.m. in the emergency department (ED) by staff #10, a nursing assistant (NA). A review of the medical records for Patient #4 revealed a Foley catheter was inserted on 05/03/25 at 1:00 a.m. on S1 by staff #21, a NA. An interview was conducted on 06/03/25 at 3:18 p.m. with staff #2, who confirmed that patient #3 and #4 had Foley catheters inserted by NAs. An interview was conducted on 06/02/25 at 9:00 a.m. with staff #3 regarding NAs and certified nursing assistants (CNA) not being allowed to perform invasive procedures, such as Foley catheters, in the state of West Virginia, as it was outside their scope of practice. Staff #3 stated: “I didn’t know that NAs and CNAs had a scope of practice. They have been inserting catheters here for decades.””

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 38282 Based on document review, medical record review, and staff interview, the hospital failed to comply with 482.23(b)(5), as Registered Nurses (RN) were delegating the insertion of Foley catheters to nursing assistants (NA), including for two (2) patients (#3 and #4); and allowing NAs and certified nursing assistants (CNA) to be trained, and oversee staff, in the insertion of Foley catheters, which is out of their scope of practice. Findings include: A review of the “Criteria for Determining Scope of Practice for Licensed Nurses and Guidelines for Determining Acts That May Be Delegated or Assigned by Licensed Nurses;” revised: 03/23/23; was reviewed, and stated in part: “Nursing practice assigned to unlicensed assistive personnel is limited to performance of the basic nursing care services, such as taking vital signs, providing personal hygiene, comfort, nutrition, ambulation and environmental safety and protection. Unlicensed workers are PROHIBITED from performing any licensed nursing function that is specifically defined for licensed nurses in the nursing practice acts or rules of the Boards of Nursing, except as specifically provided in West Virginia Code and Rules for AMAPs, School Nurses, Dialysis techs, EMS, etc ...” A review of the Rivers Health Admission Packet was completed, and stated in part: “Catheter-Associated Urinary Tract Infections: ...To prevent urinary tract infections, doctors and nurses take the following actions ...Only properly trained persons insert catheters using sterile (“clean”) technique ...” A review of the medical records for Patient #3 revealed a Foley catheter was inserted on 04/22/25 at 10:50 p.m. in the emergency department (ED) by staff #10, a nursing assistant (NA). A review of the medical records for Patient #4 revealed a Foley catheter was inserted on 05/03/25 at 1:00 a.m. on S1 by staff #21, a NA. A total of eleven (11) personnel files were reviewed - eight (8) NA and three (3) CNA. The orientation and annual trainings were reviewed, and revealed the Foley catheter trainings had been completed, but the observation check off sheets could not be located for staff #7, #14. #16, #17, #18, or #19 - all with dates of hire between 2019 and 2023. Further review of the July 2024 skills fair revealed that staff #18 had signed off the Foley catheter training for staff #7 and #10; but had no documented training for (himself/herself) for 2024. An interview was conducted on 06/03/25 at 3:18 p.m. with staff #2, who confirmed that patient #3 and #4 had Foley catheters inserted by NAs. An interview was conducted on 06/02/25 at 9:00 a.m. with staff #3 regarding NAs and certified nursing assistants (CNA) not being allowed to perform invasive procedures, such as Foley catheters, in the state of West Virginia, as it was outside their scope of practice. Staff #3 stated: “I didn’t know that NAs and CNAs had a scope of practice. They have been inserting catheters here for decades.” An interview was conducted on 06/02/25 at 8:49 a.m. with staff #4, who stated: “NAs have been inserting Foley catheters for years, at least since I started working here thirty-three (33) years ago. We start the Foley catheter training in orientation, and continue it annually within the skills fairs. An interview was conducted on 06/03/25 at 10:50 a.m. with staff #5 regarding the skills fairs. Staff #5 stated: “I assigned [staff #18] to run the Foley catheter trainings at the skills fair in July of 2024. [He/she] is a NA preceptor, and I went over the training with [him/her] again just prior to the fair. I guess I should have had an RN do it, but there were none available.” Regarding staff #18 having no documented Foley catheter skills fair training in 2024, staff #5 stated: “That was my oversight for not documenting the training.” Staff #5 denied knowledge that NAs and CNAs were not allowed to insert Foley catheters in the state of West Virginia. An interview was conducted on 06/04/25 at 9:00 a.m. with staff #6 who confirmed that when a patient is ordered to have a Foley catheter inserted, the NA assigned to the patient is responsible for inserting the catheter; and that it is up to the NA to inform the staff if they need their observation check off sheet completed or not. Staff #6 then confirmed that the Foley catheter observation check off sheets could not be located for staff #7, #14. #16, #17, #18, or #19. An interview was conducted on 06/02/25 at 1:54 p.m. with staff #7, who confirmed that they had worked at the hospital for three (3) years as a NA. Staff #7 stated: “I got training on inserting Foley catheters when I was hired. I had to be observed and signed off three (3) times before I could do them alone. I have probably put in about ten (10) to twelve (12) by myself. I will ask for help if I have a patient that cannot hold still or if they are heavy and need to be held back. If we cannot get the catheter in because they are swollen or something, we will get the RN to come and do it. Usually I just do it myself. I feel very comfortable.” An interview was conducted on 06/02/25 at 2:05 p.m. with staff #8, who confirmed they had worked at the hospital for thirty-eight (38) years as a NA. Staff #8 stated: “Over the years since I worked here, we have been trained and allowed to insert Foley catheters off and on. We have been doing them for years now, since way before Covid. I worked briefly at the nursing home, and we were not allowed to do it over there. We get trained on it every year. We get male and female dummies to practice on, then a RN signs us off. They watch us do a male, a female, and a straight cath. I have watched other techs and signed them off before, but it has been awhile.” An interview was conducted on 06/02/25 at 2:15 p.m. with staff #9, who stated: “I am a new CNA. I got the Foley catheter training in orientation. I was trained on a male and female dummy. I will be watched and signed off for three (3). The nurse educator or an RN will sign me off, then I can do it alone. I have never inserted one on a real person yet, but I watched another NA do a couple. We got a lot of training in orientation. I am seasoned, or it would have been overwhelming. I have worked at [another facility], and we were not allowed to insert Foley catheters there.” An interview was conducted on 06/02/25 at 2:35 p.m. with staff #10 who stated: “I work in the emergency department (ED) as a NA. I have worked here two (2) years, and six (6) years previously. This is the only place I’ve worked that we are allowed to put in Foley catheters. The training starts with a video, then we practice on dummies. [Staff #5] or another RN will watch us three (3) or four (4) times and we get signed off. After that we are good to go. We get a skills lab every year. I have inserted lots of catheters, probably hundreds, either Foley or straight caths. I have even done several in one (1) day in the eight (8) years I have been here.””