HospitalInspections.org

Based on record review and interviews, the hospital failed to ensure personnel met applicable standards required by State regulations for hospital personnel. This deficient practice is evidenced by failure to ensure direct care staff had the required CPI and CPR training as required by their job description.
Findings:

Review of the hospital's Job Descriptions revealed in part:

Registered Nurse - Job Requirements/Skills CPR (cardiopulmonary resuscitation) certification, CPI (Nonviolent Crisis Physical Intervention Training).

Mental Health Technician - Job Requirements/Skills CPR (cardiopulmonary resuscitation) certification, CPI (Nonviolent Crisis Physical Intervention Training).

Review of the direct care personnel's certifications revealed: 2 of 14 RN's failed to have the required CPI training certification (S3RN, S4RN); and 9 of 25 MHT's failed to have the required CPR training certification (S5MHT, S6MHT, S7MHT, S8MHT, S9MHT, S10MHT, S11MHT, S12MHT, S13MHT).

Interview on 07/23/2024 at 4:20 p.m., S2HR Director confirmed the RN's and MHT's did not have the required CPI and CPR certifications and training as required by their job descriptions.

Based on record review and interviews, the hospital failed to ensure the Quality Assurance/Performance Improvement (QAPI) program measured, analyzed and tracked quality indicators to monitor the safety and effectiveness of hospital services and operations. This deficient practice was evidenced by failing to ensure direct care staff had the required certification and training as required in their job descriptions.
Findings:

Review of the hospital's policy titled, "Plan for Staff Orientation, In-service training and Evaluation revealed in part: Policy - It is the policy of this facility to assess the learning needs of each employee upon hire, during orientation, and on an ongoing basis throughout employment.

Review of the direct care personnel's certifications revealed: 2 of 14 RN's failed to have the required CPI training certification and 9 of 25 MHT's failed to have the required CPR training certification.

Interview on 07/23/2024 at 2:27 p.m., S1Administrator confirmed all direct staff are to have CPR and CPI training and acknowledged this should have been captured as part of their quality assurance program.