HospitalInspections.org

Based on documentation review and interview, the hospital failed to ensure that three (3) of seven (7) Registered Nurses (RN's) completed their annual training on "Fall Prevention (Morse & Peds)." This failure has the potential to affect all patients receiving treatment at the hospital.

Finding are as follows:

The Annual Healthstreams 2023 training was reviewed. All nursing staff were required to take "Fall Prevention (Morse & Peds)" by 12/31/23.

A review of RN training revealed the following, including, but not limited to: "Fall Prevention (Morse & Peds)" was not completed in 2023 by RN #2, RN #3, or CC #1.

A policy titled: "Competency Assessment Process;" revised 09/20; revealed in part: "Annual verification process: ... 3. Documentation includes but is not limited to the computerized record maintained by the Clinical Training and Development Department." And: "Note: Failure to meet and provide verification of annual competency requirements as established by each unit/service may result in disciplinary action."

An interview was conducted on 01/03/24 at 2:54 p.m. with the Staff Development Instructor (SDI) regarding staff training for falls. The SDI stated, "All RN's are to complete the training in the Healthstreams electronic system titled "Fall Prevention (Morse & Peds) at hire and annually. Our department assigns the training, and it is up to the employees to complete and the managers to monitor. All annual training courses are due by 12/01 and fall out of the system on 12/30. If the employee misses the training, they will be reset for the following year. It's up to the manager to monitor and discipline." The SDI then confirmed that RN #2, hospital staff, had completed the Falls training on 11/22/22, but not in 2023. RN #3, traveler nurse, had completed the Falls training on 12/22/22. RN #3 had left employment, then returned within six (6) months, thereby not requiring the new hire training. However, RN #3 did not complete the annual training for 2023. Clinical Coordinator (CC) #1 completed the Falls training on 11/22/22, but not in 2023.

An interview was conducted on 01/04/24 at 8:59 a.m. with the Director of Emergency and Critical Care (DECC) regarding staff training for "Fall Prevention (Morse & Peds)." The DECC stated, "I delegate the monitoring of training to my front-line staff of Nurse Managers and Critical Coordinators; but it is the staff 's responsibility to complete all of their training. I get quarterly updates and am brought into it if they cannot handle a situation. In my three (3) years as Director it has not been an issue." The DECC confirmed that three (3) of the reviewed staff did not complete the required annual Fall Prevention training from Healthstreams in 2023 and stated, "For some reason the training wasn't assigned to RN #2. RN #3 and CC #1 were assigned the training but did not complete the training and were delinquent."