HospitalInspections.org

Based on record review and interviews, the facility failed to enforce its policy for training staff . Specifically, (a) Five of twenty Emergency Department (ED) nursing staff and all medical residents failed to receive the annual Mandatory Corporate Compliance and Emergency Medical Treatment and Labor (EMTALA) training and (b) four of eight nursing personnel records do not have current Basic Cardiac Life Support (BCLS) and Advanced Cardiovascular Life support (ACLS) Certifications.

Findings:

Review of the Dedicated ED personnel records and the facility Corporate Compliance Training Log, 2012, was completed on 7/18/13 and 7/19/13 and revealed the following:

a. There was no Corporate Compliance and EMTALA training record for 2012 in five of twenty nursing personnel records (#1, #2, #3, #4 and #5) and all ED residents.

Further, review of attendance rosters for ED medical staff on 7/18/13 found that no Emergency Department (ED) residents had evidence of EMTALA training. At interview with the former ED Medical Director on 7/18/13, it was stated that the there is no ED Residency program at the hospital but that there are ED Residents who rotate for a month at a time through the ED from programs based in other hospitals and that they act in reliance of the other hospitals' training program.

During an Interview with the Director of Nursing ED, on 7/18/13 at 2:00pm, the Director stated that EMTALA training is provided during the ED orientation training and annually in the facility's Corporate Compliance training, which includes EMTALA. Staff is required to complete the Corporate Compliance training during the months of September to October each year.
The attendance records for September 24th to October 19th, 2012 were given to the surveyor and the names of the nursing personnel referenced in personnel records #1, #2, #3, #4 and #5 were not found on the attendance records. A list for the ED personnel who received the Corporate Compliance training for 2012 was given to the surveyor on 7/19/13 at 11:25 am, and the referenced names were not on the list.


b. There were no BCLS or ACLS Certifications in four of eight nursing staff personnel records reviewed. No BCLS or ACLS Certification was evident in record #5, no ACLS Certification in personnel record #6, and no BCLS Certification in personnel records #7 and #8.


During and a follow-up interview with The Director of Nursing ED on 7/19/13 at 12:00pm, the director stated that nursing personnel in the ED are required to have BCLS and ACLS Certifications. Nurses who transfer to the ED are required to have both certifications within a year of transfer to the department.

Based on record review and interviews it was determined that the ED (emergency department ) log did not contain entries for all persons who present to the ED for treatment.

Findings include:

Review of the ED log for 7 months (January - July 2013) on 7/18/13 found that there is no designation for patients who walk out prior to triage.

At interview with the Vice-President for Nursing and the ED Nursing Director on 7/18/13, it was stated that they were unable to obtain any record of the encounters that are entered into the computer by the ED "greeter" in the waiting room walk in ED triage area.

Based on record review (policies) and interview it was determined that the Emergency Department (ED) formulated a policy that diverts ambulance patients from the ED to the waiting room at the discretion of the triage nurse.

Findings include:

Review of ED policy and procedure titled " Ambulance Triage " (approved/revised 9/30/11)on 7/18/13 found that it permits patients who arrive by EMS (Emergency Medical Services) to be " escorted " to the waiting room for full triage by another triage nurse if , in the opinion of the triage nurse, the patient would have been classified as ESI #4 and #5.
The Emergency Severity Index (ESI) is a five-level triage algorithm that categorizes emergency department patients by evaluating patient acuity, urgency, and resource needs.

Further, the policy documents the triage nurse to redirect the patient to the " waiting room " to be triaged by the waiting room nurse based on vital signs taken by Emergency Medical Services (EMS) enroute to the hospital. The " ambulance " triage nurse signs the ACR (ambulance call report) .

At interview with the ED Nursing Director on 7/18/13 at 10:00 AM, it was stated that this policy is in effect.