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Based on interview and record review, the facility failed to ensure that 10 of 15 Emergency Department (ED) Physicians (Staff C, R, T, JJ, MM, NN, OO, PP, RR and SS ) maintained required basic and/or advanced life saving certifications. This had the potential to lead to poor outcomes and possibly death when emergency care was necessary. There were 15 ED Physicians employed by or contracted with the facility to provide ED Care. The ED sees approximately 3800 patients per month. The facility census was 229.

Findings included:

1. Record review of the ED Physician Job Description showed that ED Physicians were required to maintain the following certifications:
- Basic Cardiac Life Support (BCLS, basic life support measures to restore pulse or breathing);
- Advanced Cardiac Life Support (ACLS, advanced life support measures, including the use of medication and artificial airways, to restore pulse or breathing);
- Pediatric Advanced Life Support (PALS, advanced life support measures provided to children, to restore pulse or breathing); and
- Advanced Trauma Life Support (ATLS, advanced measures provided to patients who present with life threatening injuries).

2. Record review of the following ED Physicians' personnel and credentialing files, (as verified by administrative staff) showed:
- Staff C did not have current certifications for ACLS, PALS or ATLS;
- Staff R did not have current certifications for BCLS, ACLS, PALS, or ATLS;
- Staff T did not have current certifications for BCLS, ACLS or ATLS;
- Staff JJ did not have current certifications for BCLS or ATLS;
- Staff MM did not have current certifications for BCLS or ATLS;
- Staff NN did not have current certifications for BCLS, ACLS, PALS or ATLS;
- Staff OO did not have current certifications for ACLS, PALS or ATLS;
- Staff PP did not have current certifications for BCLS, ACLS, PALS or ATLS;
- Staff RR did not have current certifications for BCLS, ACLS, PALS or ATLS; and
- Staff SS did not have current certifications for PALS or ATLS.

During an interview on 08/09/16 at 3:25 PM, Staff EE, Director of Human Resources and Staff QQ, Assistant Manager of Training and Development, stated that they were unable to locate current, required certifications for Staff R, ED Physician and Medical Director. Staff EE and Staff QQ added that when they searched for Staff R's certifications, they recognized a gap in the monitoring process that ensured ED Physician's maintained current, required certifications.

During an interview on 08/10/16 at 9:00 AM, Staff R, stated that his PALS was expired, and was unsure if his BCLS, ACLS or ATLS were current. Staff R stated that he typically received a reminder from an administrative assistant when he needed to renew his certifications, but had not received the reminder and therefore his certifications had lapsed. Staff R added that he was responsible for oversight of the ED Physicians, and therefore responsible for ensuring that ED Physician's were current with their required certifications.