HospitalInspections.org

Based on document review and interview, the governing board failed to ensure that one of two registration clerks had completed CPR (cardio pulmonary resuscitation) certification after hire, as required per the job description (Staff member N1), failed to ensure that two of two registration clerks had completed education courses within their 180 days of hire, as required by the job description (staff members N1 and N2) and failed to ensure that the job description for maintenance staff included security position duties and responsibilities for one of one maintenance employee (staff member N3).

Findings Include:
A. Review of the Job Description for an ECC (emergency care center) Registration Specialist indicated in section 7., Patient Safety: in item f.: Must be or become certified in CPR and remain current.

B. Review of the employee file for Registration Specialist N1 indicated this staff member was hired 2/16/15 and had no documentation in their file for CPR certification.

C. At 11:30 AM on 12/29/15, interview with staff member #54, the director of registration, confirmed that staff member N1 lacked CPR certification, as required per the job description.

D. Review of the job description for ECC (emergency care center) Registration Specialist, indicated in the section: "Education and Formal Training Required", Completed a Certified Medical Assistant program or 1st Responder course with up to date certification, or experience in a healthcare setting and be able to obtain hospital certification for an ECC Responder within 180 days of employment.

E. Review of the employee files for registration clerk N1, hired 2/16/15, and N2, hired 11/10/14, indicated there was no documentation of either having taken/completed a Certified Medical Assistant program or 1st Responder course since their dates of hire.

F. At 11:30 AM on 12/29/15, interview with staff member #54, the director of registration, confirmed that staff members N1 and N2 had not completed the course(s) required by the job description, and that both were beyond the 180 day requirement.

G. Review of the job description for Maintenance Mechanic I indicated there was nothing in the document that indicated a responsibility as security personnel when staff call an emergency code situation for security to respond to.

H. Review of the employee file for staff member N3, a mechanic/security employee hired 3/11/13, indicated there was no job description that explains the duties of a security person when called by staff for assistance in an emergency situation.

I. Review of incident/security reports indicated that staff member N3 responded to an emergency situation in the ED (emergency department) at 3:30 AM on 7/1/15, when security staff were requested.

J. At 2:15 PM on 12/29/15, interview with staff member #50, the chief quality officer, confirmed that the job description for a maintenance mechanic lacks indications, instructions, or educational requirements for acting as security for the facility in emergency situations.