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Based on employee health file review and interview, it was determined the facility failed to comply with State Regulation Section 8.D.2 regarding annual TB (tuberculin) skin tests for Physicians. The facility failed to provide evidence of a current TB skin test for six (#1-6) of 12 (#1-12) physicians. The failed practice placed patients, staff and visitors at risk for TB exposure and could affect anyone who came in contact with those physicians. Findings follow.

A. During an interview on 05/09/12 at 0900, the Credentialing Coordinator stated they only required a current TB skin test before re-appointment.

B. Review of Physician's health files revealed no evidence of a current TB skin test on file for Physicians #1-6.

C. Findings were confirmed by the Employee Health Nurse on 05/09/12 at 1105.

Based on review of Emergency Services Schedule, Medical Staff Minutes, position description, competency assessment and interviews, it was determined the facility failed to assure the Medical Staff approved privileges for individuals functioning as an Emergency Medical Technician in the Emergency Department as required by "Arkansas State Board of Health, Office of Emergency Medical Services and Trauma Systems; Rules and Regulations for Emergency Medical Services", Act 435 of 1975, Effective 06/01/08." Without approved privileges for Paramedic staff, the facility could not assure there were medical personnel qualified in emergency care to meet the emergency needs anticipated by the facility. The failed practice had the potential to affect any patient who received care at the facility. The findings were:

A. On 05/08-05/09/12, a review was conducted of the Emergency Services Schedule for 10/23-11/19/11 and 05/06-06/02/12. The schedule included the staff categories of Registered Nurse, Paramedic, Technician II, phlebotomy, and Unit Secretary. Paramedic #1 and #2 were listed on the schedules as "Paramedic".

B. The Policy and Procedure, "Assessment of the Trauma Response System" was reviewed on 05/09/12 and listed roles of the trauma team members. The "Secondary Nurse/Paramedic" role was listed as "Performs or assists with the performance of any procedures within their scope of practice." Job descriptions for Paramedic staff and Technician staff was provided on 05/09/12 at 1450 and 1445.

C. Medical Staff Minutes were provided and reviewed on 05/08/-05/09/12 and did not include documentation that criteria was established or standards of practice was delineated for Paramedics. The minutes provided did not reflect the Medical Staff, with concurrence of the hospital's Governing Body, had approved privileges for the Paramedics listed on staff in the Emergency Department. The findings were confirmed by interview on 05/09/12 with RN #5.

D. Employee files were requested and reviewed for Paramedic #1 and #2 on 05/08-05/09/12. Paramedic #1 and #2 employee files contained the document, "Position Description and Competency Assessment. Job title Paramedic". The date of the last evaluation completed for Paramedic #1 was 01/20/12. The date of the last evaluation completed for Paramedic #2 was 01/27/12.

E. The following were the competencies listed on the Position Description and Competency Assessment forms for Paramedic in Paramedic #1 and #2's employee files:

1) The category "Quality Care", item #1 stated, "The employee demonstrates an understanding of the age-specific needs, including care, communication and safety needs, for the customers they serve. Examples that meet expectations, recognizes and implements emergency care, equipment usage, medication and administration, education, comfort measures. Maintains appropriate level of knowledge/skill in managing Hazardous Material emergencies, Mass Casualty incidents and safe Helipad Operations.

2) The category Quality of Care, Item #2 stated "Employee is deemed competent in basic job skills required for this position, including: medication administration and documentation. Examples that meet expectations: following the 5 rights, double-checking MARs (medication administration records), using proper technique with medication delivery and wasting of narcotics, monitoring medication Pyxis usage, use of Care Mobile, documenting PRNs (as needed medications) and following protocols (Heparin, SSI, K+) as ordered. Documentation: pain scale, Braden scale, I and Os (Intake and output, daily weights, admission assessment, flow sheet and worksheets, moderate sedation form. Demonstrates competency in proper utilization of Department specific equipment (i.e. Ibex computer system, Ohio Unit, fetal monitor, pneumatic tourniquets, level I, Dental Unit, Decontamination Shower, Hare traction splint, EMS (Emergency medical system) radio, spinal motion restriction equipment, orthopedic/splinting equipment. Demonstrates competency in performance of Department specific procedures, (i.e. Trauma Alert Activation, Sexual Assault Examination, Evidence Collection, Drug Screen, Collection, Cardiac Conference Response, Orthopedic/Splinting techniques and IV (intravenous) therapy. Demonstrates competency of medication delivery, indications and possible adverse reactions of vasoactive drips, Thrombolytic/Fibrinolytice and Solumedrol (per spinal injury protocol).

3) The category Quality of Care, Item #4 stated, "Employee demonstrates the ability to apply the principles of nursing diagnoses through assessment of patients, creation and integration of an effective plan of care and critical thinking. Examples that meet expectations: reassessment of patients, integration of an effective plan of care and critical thinking."

F. In an interview with the Director of Emergency Services on 05/09/12 at 1438, regarding the "Paramedic staff", she stated "I was told because they work as technicians under a Registered Nurse (RN) they don't have to be credentialed. "Surveyor #1 asked the Director of Emergency Services about the job descriptions for Paramedic #1 and #2, as they were for "Position Description and Competency Assessment. Paramedic". The Corporate Compliance Officer stated on 05/09/12 at 1440 that "the job descriptions are incorrect".

G. Registered Nurse #1, #2 were interviewed on 05/09/12 at 1530 and stated (named) Paramedic staff functioned as "Technicians". RN #3 stated 05/09/12 at 1533 "I think they can do IVs and Lab, but they work as Techs (Technicians)".