HospitalInspections.org

Based on review of Emergency Room schedule, EMT (Emergency Medical Technician) employee files and interview, it was determined the Facility Failed to assure 1 (#3) of 3 (#1-#3) EMT staff, who work in the |Emergency Room, had Medical Staff approval for individual privileges and approved by the Governing Body. The facility could not assure the EMT practice was within their qualifications and the established criteria as determined by the Medical Staff and approved by the Governing Body. The failed practice had the potential to affect the average daily census of 70 patients. The findings were:

A. Review of the Emergency room schedule for 08/20/12-09/30/12 revealed four EMTs were listed on the schedule. EMT #4 was newly hired and had not been scheduled any days. Employee files were requested for EMT #1, #2 and #3. EMT #1 and #2 were credentialed and approved by the Governing Body. EMT #3 did not have evidence of approval and credentialing.

B. In an interview with the Director of Patient Safety/Corporate Compliance Officer on 09/27/12 at 1315, she stated EMT #3 had not been credentialed. The individual responsible for Physician and Allied Health credentialing was interviewed on 09/27/12 at 1320 and confirmed MT #3 had not been submitted for credentialing. The Emergency Department Manager confirmed the findings on 09/27/12 at 1325 and stated MT #3 had been working in the Emergency Department as an MT since 11/2010.