HospitalInspections.org

Based on review of an agency contract, policy and procedure, review of contract employee files and interview, the facility failed to ensure 2 of 2 contract hemodialysis (HD) nurses participated in annual mandatory training. (LPN #10 and LPN #11)

The findings include:

Review on 11/29/2016 of the "OUTSIDE SERVICES AGREEMENT" (dated May 5, 2015) revealed, "... SERVICES OF CONTRACTOR ...5. CONTRACTOR staff competency is completed per HOSPITAL requirements as well as service line specific requirements annually (or more frequent) (Goal 100%) ..."

Review of the contracted agency policy and procedures "Dialysis Nurse's Requirements" (revised 10/27/15), revealed "... The [Agency name] Dialysis Service's personnel will meet the requirements per [facility name] Agency Staff Policy. Review of "Education" (revised 10/27/15) revealed, "... The educational activities can include, but are not limited to: Attendance at hospital in-services, seminars and/or mandatory classes; ..."
Continued review of "Mandatory In-Services" (revised 10/27/15) revealed, "Each acute dialysis unit is responsible for scheduling the in-services for all personnel. ... Mandatory in-service occurs as "on duty' time. The employee must also meet annual [facility name] specific requirements."

Review of the hospital policy and procedure "Annual Continuing Education by Service Line" (revised 12-2015) revealed, "... 5) methods of completing the required continuing education may include computer-based training, self-learning modules, skill stations, mock codes, written test, and/or return demonstrations. Employees of Patient Care Services are required to complete mandatory educational activities prior to the annual performance evaluation due date as dictated by the following: I. Hospital required reviews ... II. Additional requirements for Patient Care Services: a. Restraint training ... All providers with direct patient care are responsibility for patients are required to complete the annual CBL (computer based learning) and return demonstration at the skills fair. In addition NCI Prevention (level) training should be completed during their orientation period and annually. ... c. Skills Fair - Hospital - wide ... Nursing staff in Patient Care Services are required to attend to validate core nursing competencies. ..." Further review of "Corporate Continuing Education Requirements" (revised 02-2015) revealed, "... The educational year for each employee runs annually from the employee's date in position. All requirements must be completed prior to this date. ... The Clinical Version is for all [facility name] employees and agency staff who provide direct patient care. This group includes, but is not necessarily limited to licensed, registered and certified clinical staff. ..."

1. Review on 11/30/2016 of the educational file for LPN #10 revealed an educational transcript. Review revealed the most current trainings that occurred where on: 07/27/2016 Diversity and Inclusion CBL and Required Review CBL; 07/30/2015 Blood Administration CBL, Restraints CBL and Basic Proficiency in Medication Administration CBL. Review revealed no documentation that LPN #10 attended the annual skills fair for core nursing competency validation. Review revealed no CBL mandatory education or skill fair attendance documented for the year 2016. Further review revealed no documented competency that was signed off by the nephrologist in LPN #10's education file.

Interview on 11/30/2016 at 1100 with AS #1 and AS #2 revealed Agency staff were required to complete mandatory CBL trainings and skills fairs. Interview revealed Skills fairs occurred quarterly at the campus where the contract HD nurses were assigned. The interview revealed the contracted HD nurses needed to complete the mandatory CBL training and attend the annual skills fairs. Interview revealed LPN #10 did not complete their 2016 mandatory trainings or attend the skills fair for validation of nursing competency. The interview confirmed the review finding.

2. Review on 11/30/2016 of the educational file for LPN #11 revealed an educational transcript. Review revealed the most current trainings that occurred where on: 05/01/2015 Required Review CBL, Restraints CBL, Basic Proficiency in Medication Administration CBL and Blood Administration CBL; 6/24/2015 Active Shooter CBL and Diversity and Inclusion CBL. Review revealed no documentation that LPN #11 attended the annual skills fair for core nursing competency validation. Review revealed no CBL mandatory education or skill fair attendance documented for the year 2016. Further review revealed no documented competency validation form that was signed off by the nephrologist in LPN #11's education file.

Interview on 11/29/2016 at 1330 with LPN #11 revealed she was scheduled 4 days per week at the hospital and was called in on a daily basis as needed. The interview revealed that she completed mandatory in-services on line because that was required of the contract worker. Interview revealed the nephrologist watched her perform a full HD treatment on a patient in the unit and then the nephrologist signed off an annual HD skills competency validation form.

Interview on 11/30/2016 at 1100 with AS #1 and AS #2 revealed Agency staff were required to complete mandatory CBL trainings and skills fairs. Interview revealed Skills fairs occurred quarterly at the campus where the contract HD nurses were assigned. The interview revealed the contracted HD nurses needed to complete the mandatory CBL training and attend the annual skills fairs. Interview revealed LPN #11 did not complete their 2016 mandatory trainings or attend the skills fair for validation of nursing competency. The interview confirmed the review finding.

Interview on 11/30/2016 at 1200 with a nephrologist revealed, annually he watched the dialysis nurses provide care to assure HD competency. Interview revealed his responsibility was to ensure quality treatment were being performed. Interview revealed the dialysis supervisors performed the quality audits and reported the results to him on a quarterly basis.

NC00122933,NC00122349