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Based on interview and document review, the facility failed to ensure appropriately trained nursing staff was available at all times and on all nursing units by allowing staff members to practice without evidence of current, documented certifications of emergency training (See A0392 for details). This has the potential for the delayed and/or inappropriate provision of nursing care for all in-patients in the facility, with possible negative outcomes.

Findings include:

The facility failed to ensure nursing staff was appropriately trained in emergency procedures (Cross-reference A 0392). The facility failed to ensure appropriately trained nursing staff was available at all times and on all nursing units by allowing staff members to provide direct patient care with no documented certification of emergency skills in cardiopulmonary resuscitation (CPR).

During an interview with the Quality and Performance Specialist (QA Specialist) on 01/24/20 at 11:30 AM the QA Specialist stated facility job descriptions for all direct patient care staff do have a requirement for a current CPR card. The Quality Specialist stated that the United States Virgin Island Board of Nursing requires proof of a current CPR card for nurses' application for license renewal but added that errors had occurred in the past due to a valid CPR card expiring during the renewal process. The QA Specialist stated that the facility expectation is for the Chief Nursing Officer to maintain oversight and for Nurse Managers of each nursing unit to track staff training needs and provide the documented evidence of trainings to Human Resources (HR).

On 01/24/20 at 2:55 PM Nurse Managers (NM) 8, 15, 16, and 17, all four NM confirmed there was no specific system in place to notify them when a staff member was due for their CPR recertification.

A complete roster of the facility's 125 RNs and the files containing documented evidence of licenses and CPR cards was provided and reviewed on 01/24/20 at 5:30 PM. All documented evidence of CPR certifications was compared to the roster in the presence of the QA Specialist and the CNO. All RNs had current license. Forty-three of the RNs had no documented evidence of CPR certification.

This deficient practice had the potential to have untrained staff members caring for in-patients on all nursing units, with a possible delayed and/or inappropriate response during an emergency cardiac or respiratory event (Code Blue), with possible negative outcomes.

Based on interview and document review, the facility failed to ensure appropriately trained nursing staff was available at all times and on all nursing units by allowing staff members to provide direct patient care with no documented certification of emergency skills in cardiopulmonary resuscitation (CPR). This had the potential to have untrained staff members caring for in-patients on all nursing units, with a possible delayed and/or inappropriate response during an emergency cardiac or respiratory event (Code Blue), with possible negative outcomes.

Findings include:

The personnel file of Registered Nurse (RN) 10 was reviewed on 01/24/20 and was found to contain a CPR card (documented evidence of completion of the CPR class) which had expired 11/30/17.

During an interview with the Quality and Performance Specialist (QA Specialist) on 01/24/20 at 11:30 AM the QA Specialist stated facility job descriptions for all direct patient care staff do have a requirement for a current CPR card. At this time, the QA Specialist placed a phone call to RN 10 and then stated that RN 10 confirmed having a CPR card which had expired in 2019. The Quality Specialist stated that the United States Virgin Island Board of Nursing requires proof of a current CPR card for nurses' application for license renewal but added that errors had occurred in the past due to a valid CPR card expiring during the renewal process. The QA Specialist stated that the facility expectation is for the Chief Nursing Officer to maintain oversight and for Nurse Managers of each nursing unit to track staff training needs and provide the documented evidence of training to Human Resources (HR).

During an interview with the Chief Nursing Officer (CNO) on 01/24/20 at 1:25 PM, the CNO stated, "The managers should have a spread-sheet list of staff, with monthly expiration dates, then schedule training as needed prior to expiration." The CNO stated that the documented evidence of completed CPR training would be provided to HR. The CNO stated he/she had been unaware of the system failure. The CNO stated that all incident reports related to problems with Code Blue responses throughout the facility would come to the desk of the CNO and no such incidents had been reported during the previous year.

On 01/24/20 at 2:55 PM Nurse Managers (NM) 8, 15, 16, and 17, all four NM confirmed there was no specific system in place to notify them when a staff member was due for their CPR recertification. NM16 stated she used her individual file for each of her staff to check on a monthly basis to see who was due. NM17 confirmed she used the same type of system to know when a staff member needed to recertify. All four NM's stated it was possible for staff to get " ...overlooked ...," NM8 stated a local agency offers a CPR recertification class monthly. The local agency notifies all hospital department heads and educator of the scheduled date, notices are posted throughout the hospital and the staff are responsible for notifying the educator to reserve them a spot. NM8 further stated the agency sends a sign-in sheet to the human resource department after the class so the hospital can verify who attended.


A complete roster of the facility's 125 RNs and the files containing documented evidence of licenses and CPR cards was provided and reviewed on 01/24/20 at 5:30 PM. All documented evidence of CPR certifications was compared to the roster in the presence of the QA Specialist and the CNO. All RNs had current license. Forty-three of the RNs had no documented evidence of CPR certification.

A policy related to CPR certification for nurses was unavailable. Review of the "Job Description Registered Nurse," revealed, "Minimum Qualification ...Possession of a Current CPR Card."

Based on interview, review of documents, and review of facility policy and procedure, the facility failed to maintain professionally approved standards for qualifications of personnel in the Radiology Department by allowing staff members with expired emergency training certifications to continue care of patients presenting for radiological services (See A0547 for details). This placed all patients receiving radiological services at risk of delayed or inadequate care in an emergency, with possible negative outcomes.

Findings include:

The facility failed to ensure five of seven staff members in the Radiology Department were trained in emergency procedures. Failure to maintain emergency procedure skills had the potential to cause a delayed or inadequate response, placing all patients receiving services in the Radiology Department at risk of negative outcomes including death.

The Acting Director admitted awareness of a department policy requiring all direct-patient care staff to have current CPR certification. The Acting Director admitted failing to maintain oversight of these staff certifications and ensure compliance. This non-compliance put patients at risk to receive prompt necessary treatment to maintain life in an emergency situation.

Based on interview and review of documents, the facility failed to ensure five of seven staff members in the Radiology Department were trained in emergency procedures. Failure to maintain emergency procedure skills had the potential to cause a delayed or inadequate response, placing all patients receiving services in the Radiology Department at risk of negative outcomes.

Findings include:

During review of the personnel file of Staff 14, Acting Director of Radiology, on 01/24/20, the CPR (cardiopulmonary resuscitation) card had an expiration date of 08/31/19.

During review of the personnel file of Staff 20, Radiology Technician, on 01/24/20, the CPR card had an expiration date of 12/31/19.

During review of the personnel file of Staff 21, Radiology Technician, on 01/24/20, the CPR card had an expiration date of 07/15.

During review of the personnel file of Staff 22, Radiology Technician, on 01/24/20, the CPR card had an expiration date of 03/18/17.

During review of the personnel file of Staff 23, Radiology Technician, on 01/24/20, the CPR card had an expiration date of 08/31/19.

During an interview with the Acting Director of Radiology (Acting Director) on 01/24/20 at 11:30 AM, the above documentation was reviewed. The Acting Director admitted awareness of a department policy requiring all direct-patient care staff to have current CPR certification. The Acting Director admitted failing to maintain oversight of these staff certifications.

Review of the facility's policy titled, "CPR certification; Scope: Diagnostic Imaging," effective date September 2015, revealed, "All employees involved in direct patient care should be CPR certified upon employment or within the 90-day probationary period."

Based on a Life Safety Code (LSC) Recertification survey, completed on February 27, 2020 , at Gov Juan Luis Hospital & Medical Center, the condition for Physical environment is not met. See Form CMS-2567 Life Safety Code report for cited deficiencies.

The Findings Include:

Refer to K tags, K345 and K353 in LSC 2567.

Based on observation, interview, and review of facility policy and procedure, the facility failed to ensure availability of viable supplies in three of three emergency carts (crash carts) in the Emergency Department (ED). This failure had the potential to delay an emergency response, placing all patients presenting to the ED with an emergency medical condition at risk of negative outcomes.

Findings include:

During a tour of the ED on 01/21/20 at 11:50 AM attended by the Nurse Manager (NM/ED) and the Chief Nursing Officer (CNO), all three of the ED-dedicated crash carts were examined.

In Room 12, an adult crash cart was found to contain the following items: two endotracheal tubes (ET tubes/tubes used to maintain and airway and/or deliver supplemental oxygen to a patient in respiratory distress) one with a expiration date of 03/19 and one with an expiration date of 07/17 and five packages of sterile surgical gloves, all with expiration dates of 10/19.

In Room 11, an adult crash cart was found to contain the following items: one ET tube with an expiration date of 07/19 and four packages of sterile surgical gloves with expiration dates of 03/19, 09/19, 12/19, and 12/19.

In Room 9, a pediatric crash cart was found to contain the following items: one ET tube with an expiration date of 07/19 and two packages of sterile surgical gloves with expiration dates of 10/19 and 6/19.

In a joint interview with the NM/ED and CNO on 01/21/20 at 12:40 PM, the NM/ED stated that nursing staff is expected to check expiration dates and replace expired supplies on a monthly basis. Both agreed facility expectation is for staff to remove all expired supplies from patient care areas.

Review of the facility's policy titled, "Emergency Crash Carts," last revised 12/17 revealed, "The indication of expiration dates shall be used to ascertain that all items stored on the cart are within the dating limits. This check shall be conducted at least once a week by the nursing staff. If a product is expired or shall become expired before then (sic) next scheduled Nursing Review ...Nursing will review and re-stock other items on crash cart prior to re-locking."