HospitalInspections.org

Based on review of facility documents, credential files (CF) and staff interview (EMP), it was determined the facility failed to ensure Emergency Department medical staff and nursing staff had the required training for one of five credential files (CF2) and one of six personal files (PF2) reviewed.

Findings include:

1) Review on February 20, 2015, of the facility's "Medical Staff Bylaws," last revised and amended January 2015, revealed "... Article 7 - Clinical Privileges 7.1 Process for Privileging and Re-Privileging ... (b) Basic Requirements of Process In order for a request for privileges to be processed, the applicant must satisfy the following eligibility criteria: ... (xi) all emergency medicine physicians must have a current BLS [Basic Life Support], PALS [Pediatric Acute Life Support], ACLS [Advances Cardiopulmonary Life Support] and ATLS [Advanced Trauma Life Support] certificate; ..."

Review on February 20, 2015, of the facility's "Credentialing Policy," last approved and adopted by the Board of Directors January 2015, revealed "Qualification, Conditions and Responsibilities 2.A Qualifications 2.A.1. Eligibility Criteria: To be eligible to apply for initial appointment or reappointment to the Medical Staff, physicians, dentists, and podiatrists must: ... (l) all emergency medicine physicians must have a current BLS, PALS, ACLS and ATLS certificate; ..."

Review on February 19, 2015, of CF2 revealed this practitioner's ATLS certification expired on September 3, 2014. There was no documentation this practitioner completed an ATLS re-certification course prior to the expiration on September 3, 2014, or that CF2 had a current ATLS certificate.

Interview with EMP1 and EMP2 on February 20, 2015, at approximately 11:15 AM confirmed this finding.

Review on February 20, 2015, of the facility's Emergency Department (ED) physician coverage schedule revealed CF2 worked the following schedule in the ED: September 8, 10, 12, 15, 18 and 24, 2014; October 8, 14, 17, 19, 22 and 30, 2014; November 4, 7, 10, 14, 19 and 26, 2104; December 4, 8, 16, 19, 22 and 30, 2014; January 2, 9, 13, 16, 21, 27 and 30, 2015; and, February 3, 7, 11, 13 and 19, 2015.

Interview with EMP1 on February 20, 2015, at approximately 12:00 PM confirmed this finding.

Review on February 20, 2015, of the facility's Credentialing Committee meeting minutes for September 3, 2014; October 1, 2014; November 5, 2014; December 3, 2014; and, January 7, 2015, revealed no documentation the facility addressed CF2's expired ATLS certificate.

Review on February 20, 2015, of the facility's Credentialing Committee meeting minutes for February 4, 2105, revealed the committee addressed CF2's expired ATLS, CF2 was scheduled to renew the ATLS certificate on March 6, 2015. Reappointment was approved pending ATLS recertification, and temporary privileges were granted.

Interview with EMP1 and EMP2 on February 20, 2015, at approximately 12:15 PM confirmed this finding.

2) Review on February 20, 2015, of the facility's "Professional Nurse - Emergency Room" job description, last revised January 2008, revealed "I. Purpose The professional Emergency Room nurse is responsible for the supervision, direction, implementation and evaluation of quality patient care during the assigned work hours. ... IV. Job Qualifications ... C) License, Certification, Registration [and] Evaluation Current Pennsylvania license as a registered professional nurse. BCLS certification required. ACLS certification required within (1) year of employment. PALS certification required within (1) year of employment. ..."

Review on February 20, 2015, of PF2 revealed the employee's BLS [Basic Life Support] certification expired November 2014. PF2 worked during the months of November and December 2014, and January 2015. Further review of PF2 revealed the employee resigned employment at the facility on February 1, 2015. There was no documentation in PF2's personnel file of current BLS re-certification.

Interview with EMP1 on February 20, 2015, at approximately 9:30 AM confirmed PF2 BLS certification expired November 2014, PF2 worked during the months of November and December 2014, and January 2015, and PF2 resigned employment at the facility on February 1, 2015. EMP1 confirmed there was no documentation in PF2's personnel file of current BLS re-certification.

Repeat deficiency cited May 5, 2011