HospitalInspections.org

Based on record reviews and interviews, the facility failed to ensure that the competencies of ten of eleven nursing staff who worked in the facility emergency department (ED) were verified according to facility policy and procedures. This had the potential to affect the quality of care received by patients in the emergency department.

Findings included:

Record review on 09/18/13 of a facility policy/procedure entitled Nurse Staffing Plan and Advisory Committee, revised 12/11, revealed but was not limited to the following: " There are policies and procedures that require: Orientation of nurses and other personnel who provide nursing care to all units to which they are assigned on either a temporary or permanent basis; that the orientation of nurses and other personnel and the competency to perform nursing services is documented with accordance with hospital policy' that nursing staff be congruent with documented competency.

Record review on 09/18/13 of six registered nurses' (RN) training records for 2012 to 2013 revealed that five of six of these registered nurses (RN #!, RN #2 RN #3, RN # 4 and RN #5) self-completed a Checklist entitled Emergency Room Trauma Orientation and/or a Basic Skills Checklist and revealed that no one had signed off on the these checklists verifying the competencies of these registered nurses to work in the facility emergency room.

Record review on 09/18/13 of five licensed vocational nurses (LVN) training records for 2012 to 2013 revealed that five of five licensed vocational nurses (LVN #1, LVN #2, LVN #3, LVN #4, and LVN #5) self completed a checklist entitled Emergency Room Trauma Orientation and/or a Basic Skills Checklist and revealed that no one had signed off on these checklists verifying the competencies of these licensed vocational nurses to work in the facility emergency room.

Record review on 09/11/13 of facility nurse staffing for 09/11/13 revealed RN #3 and LVN #1 were working the 7:00 AM to 7:00 PM shift.

Interview on 09/11/13 at 1:30 PM with facility Chief Executive Officer confirmed the facility utilizes their registered nurses and licensed vocational nurses on the medical/surgical unit and the emergency department.

Interview on 09/11/13 at 2:00 PM with Emergency Department (ED) Nurse Manager confirmed that facility nursing staff rotate on a two week basis between the medical/surgical unit and the ED.

Interview on 09/18/13 at 1:45 PM with facility Director of Nursing (DON) confirmed the facility did not have specific ways of ensuring the competencies of nursing staff who worked in the emergency department.