HospitalInspections.org

Based on review of personnel files, job description and competency, Emergency Department Staffing logs and interview, it was determined the Facility failed to assure one (#2) of four (#1, #2, #3, and #4) Registered Nurses (RN) from the Central Based Pool, assigned to the Emergency Department, had evidence of ACLS (Advanced Cardiac Life Support) as required by job description and interview. The Facility could not be assured RN #2 was qualified in skills required for Advanced Cardiac Life Support. The failed practice was likely to affect any patient assigned to the care of RN #2. The findings were:

A. On 02/15/17 and 02/16/17 personnel names were selected from Emergency Department staffing lists for 10/16/16 -02/14/17. RN #1 - #4 from the Central Based Pool, who had worked in the Emergency Department, were among those selected. Review of the personnel files on 02/16/17 and 02/17/17 revealed RN #2 did not have evidence of ACLS. This was confirmed by the Facility Compliance Coordinator at the time of review.

B. In an interview with the Chief Nursing Officer on 02/15/17 at 1412 revealed there was one job description for all Registered Nurses. Each RN will have general training and orientation plus Unit specific orientation and training.

C. The Nurse Manager for Emergency Services and Trauma Services was interviewed on 02/16/17 at 0855 and stated all RN staff in the ED had ACLS.

D. The Facility Compliance Coordinator was given an opportunity to provide evidence of ACLS for RN #2 prior to the exit conference on 02/17/17. At the time of the exit conference on 02/17/17 at 1225 there was no evidence provided of ACLS for RN #2.

E. The job description for RN Emergency Department staff was requested on 02/15/17. The Facility Compliance Coordinator stated on 02/15/17 at 1416 that there was "one job description for all RNs." Review of the Registered Nurse job description revealed "Unit required certifications must be obtained within six months of hire." Review of the "Registered Nurse Emergency Department Specialty Tool" revealed "Demonstrates appropriate education by completing w/in (within) 6 months of hire: ACLS." The hire date of RN #2 was 08/2014.