HospitalInspections.org

Based on record review and interview, the facility failed to ensure that all medical staff members throughout the organization maintained current hospital required competencies.

Findings include:

-Review of provider credential files on 9/8/2023, revealed that for 1 of 11 providers (staff #39) Advanced Cardiac Life Support (ACLS) certification had expired in 3/2023.

-A 9/8/2023 review of the "Medical Staff Bylaws & Medical Staff Rules & Regulations", last amended on 3/15/2023, states "Members of the Medical Staff who actively manage patients in the ICU will have ACLS Certification".

-The Executive Directive of Quality, Regulatory, and Performance Improvement stated on interview at 10:00 AM on 9/12/2023 that the provider completed his ACLS certification on 9/11/2023 (during the State Agency survey).

Based on record review and interview, 14 of 45 medical records reviewed during the survey at Columbia Memorial Hospital (CMH) (9/7-9/13/2023) lacked general consent forms or the general consents on file were incomplete.

Findings:

-CMH Family Medicine Outpatient Services was surveyed on 9/7/2023. In medical records #10, #11, #12 and #13 general consents were not dated and timed; Medical record #14 lacked a general consent form.

-CMH Rehabilitation Services was surveyed on 9/7/2023. Medical records # 7, #8, and #9 lacked general consent forms.

-Inpatient charts were reviewed on 9/12/2023. Medical records #1, #2, #3, #4, #5, and #6 lacked general consent forms.

This was verified with the Executive Director of Quality, Regulatory and Performance Improvement (staff #1) on 9/12/2023.

Per facility policy entitled "Columbia Memorial Hospital General Consent for Treatment and Assignment of Benefits," all general consents must be signed, witnessed, and dated and in the medical record. the policy was reviewed on 9/8/2023.

Based on record review and interview, the facility failed to ensure that all nursing staff throughout the organization maintained current hospital required competencies.
Findings include:

Review of personnel files conducted on 9/12/2023 found that 1 of 13 nursing staff (staff # 41) had expired basic life support certification.

Per review of the list of requirements for "RNs/LPNs/Office Nurses/RT" on 9/12/2023, it lists BLS (basic life support) as one of the organization's requirements for employment.

The Executive Director of Quality, Regulatory, and Performance Improvement confirmed on interview on 9/13/2023 that the BLS certification of staff # 41 was expired.