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Based on interview and record review the facility failed to ensure the nursing personnel were qualified in emergency care to meet the written emergency procedures and needs anticipated by the hospital. Eight of eight nurses that work in the emergency department had either expired or no Advanced Pediatric Life Support (PALS) Certification, Trauma Nursing Core Course (TNCC) Certification, or Advanced Cardiac Life Support (ACLS) Certification.

Findings Include:

Review of the Emergency Department Nursing Personnel Trauma Pre-Survey Questionnaire presented to this surveyor on 6/14/22 by staff # 16 (Trauma Nurse Coordinator) reflected the following:
Staff #16 Expired PALS Certification
Staff #17 No TNCC Certification
Staff #23 No PALS Certification
Staff #27 No ACLS or PALS Certification
Staff #28 Expired PALS and TNCC Certification
Staff #29 Expired PALS Certification
Staff #30 Expired PALS Certification
Staff #31 No TNCC Certification

Interview with staff #26 verified the above information. She verified that all staff that work in the Emergency Department should have the above certifications.

The facility failed to ensure that medical record entries were dated, timed, and authenticated consistent with its policies and procedures.

Findings include:

The facility's Medical Staff Rules and Regulations read [in part],
"A medical record that is not completed by the physician within 30 days of discharge will be classified as delinquent. A written notice will be sent by the Medical Records Director to each physician on the 20th day post discharge, listing incomplete charts and notice that if these charts are not completed by the 30th day post discharge then their admitting privileges may be suspended until these charts are completed."

A review of the facility's incomplete charts and notices revealed staff # 11 delinquent 49 days for two charts, staff #12 delinquent 33 days for one chart, and staff #13 delinquent 41 days for one chart.

A review of the physician emergency room schedule for May 2022 revealed staff #13 was scheduled for May 23rd and May 24th despite being listed on the physician incomplete charts lists.

Findings validated by staff #16. In a personal interview on 6/14/22 in the facility's conference room, staff #16 stated, "Yes, He [staff #13] appears to have worked in the emergency room with a delinquent chart."

Based on observation, interview, and record review, the facility failed to provide a clean and sanitary environment to avoid sources and transmission of infection when disinfecting the blood glucose monitor.

Findings include:

During an interview, on the morning of 6/13/22, while touring the facility's Laboratory, when asked how she disinfects the blood glucose monitor, Staff # 24, Medical Technologist stated, "I wipe it with these wipes (Super Sani-Cloth Surface Disinfectant Germicidal Wipes) and let it dry." When asked what the contact time for the wipes was, she replied "After it is dry it is ready." Review of the Sani-Cloth directions for use reflected the contact time is 2 minutes.


Review of facility policy and procedure "ACCU-CHEK Inform II Glucose", revised August 2014 reflected,
"Meter and Base Unit Cleaning and Disinfecting:
Cleaning and disinfecting the exterior surface of the meter with either Clorox Bleach Wipes is, at minimum, recommended daily for dedicated patient devices. Meters used with multiple patients may require more frequent cleaning and disinfecting. NOTE: Follow all facility safety and infection control policies when handling, cleaning, and disinfecting ACCU-CHEK Inform II meters ..."

Staff # 25, Director of Laboratory, verified these findings.