HospitalInspections.org

Based on interviews and a review of documentation, the facility did not have adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility.

Findings were:

A review of BLS (basic life support), ACLS (advanced cardiac life support) and PALS (pediatric advanced life support) certifications was conducted while reviewing the personnel files for 10 emergency room nurses (staff #1 through #10). Interviews were conducted with 4 randomly-chosen nurses (staff #1, #4, #7 and #10) of the 10 personnel files reviewed. Of the 4 nurses interviewed, 3 of the 4 nurses held invalid certifications. Findings were as follows:

* In an interview with staff #1 on 6-5-18, staff #1 was asked who her instructor was for BLS, ACLS and PALS and where each class had been taken. Staff #1 stated that all 3 classes had been taught by staff #22 in the FSH [Foundation Surgical Hospital] emergency department. When asked if any other instructors had been present or assisted with the courses, staff #1 stated that there had not been any instructors present for the courses, other than staff #22.

Staff #1's BLS card and PALS certification cards stated that both courses had been taught by (outside) staff #23, at (outside) staff #23's residence. Staff #1's ACLS certification card stated that her ACLS course had been taught by staff #22 in the FSH emergency department. The instructor information listed on staff #1's certification cards did NOT correspond with the instructor information staff #1 provided to the surveyor. In addition, staff #21 (program director for outside company) stated in an interview that staff #1's BLS card was invalid, due to it being hand-written.

* In an interview with staff #4 on 6-6-18, staff #4 was asked who her instructor was for BLS, ACLS and PALS and where each class had been taken. Staff #4 stated that all 3 classes had been taught by staff #22 in the FSH emergency department. When asked if any other instructors had been present or assisted with the courses, staff #4 stated that an additional instructor had assisted with the PALS course, but that she did not know the instructor's name.

Staff #4's BLS and PALS certification cards stated that both courses had been taught by (outside) staff #23, at (outside) staff #23's residence. Her ACLS certification card stated that her ACLS course had been taught by staff #22 in the FSH emergency department. The instructor information listed on staff #4's certification cards did NOT correspond with the instructor information staff #4 provided to the surveyor.

* In an interview with staff #10 on 6-6-18, staff #10 was asked who his instructor was for both ACLS and PALS and where each class had been taken. Staff #10 stated that both classes had been taught by staff #22 in the FSH emergency department. When asked if any other instructors had been present or assisted with the courses, staff #10 stated that there had not been any instructors other than staff #22.

Staff #10's ACLS certification card stated that his ACLS course had been taught by staff #22 in the FSH emergency department, but his PALS certification card stated that his PALS course had been taught by (outside) staff #23, at (outside) staff #23's residence. The instructor information listed on staff #10's certification cards did NOT correspond with the instructor information staff #10 provided to the surveyor.

In interviews with (outside staff) #21 on 6-5-18 and again on 6-6-18, the staff member was asked to explain how the [outside company name] was responsible for issuing certification competencies such as BLS/ACLS/PALS. Staff #21 stated that he was the Program Director for [outside company name].

Staff #21 explained that individually certified instructors could be independently "aligned" through [outside company name] (a company authorized by the American Heart Association® to issue certification for BLS/ACLS/PALS). He stated that the instructors worked independently and could teach courses at a variety of places including their homes, healthcare facilities and other locations. He stated that the instructors would charge a fee per student (a fee determined by the individual instructor), teach the class and have the students sign a roster indicating that they had taken the particular course. The instructor would then send the roster electronically to him (staff #21) along with the fee [outside company name] charged per student and staff #21 would complete a card for each student listed on the roster. The cards would then be sent to the instructor that had taught the class for distribution to the individual students/certification recipients. When asked if there was any documentation provided to him (staff #21) to prove that the student had actually taken the class (written tests etc), staff #21 stated that there was not, as the [outside] company worked on an "honor system" and rosters were accepted as proof that the individuals listed had taken the course.

A list of 10 employees (staff #1 - #10) was reviewed with staff #21 to verify that rosters had been received for classes from one of the instructors aligned with [outside company name]. Staff #21 was able to verify that he had rosters for all courses for all above listed employees with the exception of staff #1's BLS certification. When told that staff #1's BLS certification card was hand-written with staff #1's name, course date and recommended renewal date, staff #21 stated that staff #1's BLS card was not authorized through [outside company name], as all of their cards are typed and staff #21 typed them himself. When asked how cards could be issued with one instructor's name on them if the employee stated that a different instructor had taught their class, staff #21 stated that he was unsure how that could happen.

* In an interview with (outside) staff #23 on 6-5-18, staff #23 was asked if he had taught BLS/CPR/ACLS to any FSH employees. Staff #23 stated that he would have no way of knowing where his students were employed, as he taught the majority of people at his home in El Paso and students did not list their employer. Staff #23 stated that, when courses were taught at his home, the card would be issued stated a course location of "[staff #23's last name]".

When asked if he ever taught classes for those courses on-site at FSH (instead of his personal residence), staff #23 stated that he had. When asked if he knew staff #22 or taught a class at FSH with him, staff #23 stated that he did not know staff #22. He stated that he had taught classes at FSH in the past with another instructor from [outside company name] but that the other instructor was not staff #22. When asked if he had ever inadvertently issued a certification card indicating the wrong location where the course took place, staff #23 stated that he had not. When asked if he had ever issued a student a hand-written certification card, staff #23 stated that he had not and that all certification cards were issued through [outside company name] and were type-written.

* In an interview with staff #22 on 6-5-18, he was asked how long he had been employed with FSH. Staff #22 replied, "August 2013, I think going on 5 years".
Staff #22 was shown the CPR card for staff #1 issued 03/01/18 with letter signed by [staff #22] that stated staff #1 took the course on 02/23/18. Staff #22 was asked about the date discrepancy and replied, "I guess when they process the card, there's a possibility of discrepancy." Staff #22 was informed that staff #23 was listed on staff #1's card as the course instructor. Staff #22 stated, "Right. May I see that?" Staff #22 looked at documentation and replied, "I don't know why there are two different handwritings to begin with. I see what you're saying."
Staff #22 was asked who taught the class and staff #22 replied, "I wrote the letter. I don't recall to be honest."
The surveyor stated she had spoken to staff #21 at [outside company name] and that he was over the program for this and staff #22 stated "That's what it looks like, yes."
Staff #22 was informed that all CPR cards are typed per staff #21. He replied, "He's [staff #21] absolutely right". When asked why this card would not be typed (indicating it's authenticity), staff #22 replied, "I can't recall".
Staff #22 was asked about his association staff #23. Staff #22 replied, "I met the guy once in a while. He's a co-worker. He does not work in the hospital. He's a medic, works for a private ambulance".
He was asked if he taught classes with staff #23, staff #22 responded, "We do. I don't know him really well." When staff #22 was informed that staff #23 stated he did not know staff #22, staff #22 replied, "Oh wow. That's funny. I don't know why he might say that. I don't have an answer for that for you." Staff #22 added, "I don't know how the card got in there."
Staff #22 was asked if the CPR card not being authentic make staff #1's BLS invalid. Staff #22 replied, "yeah that is correct".
Staff #22 was asked, "Have you [staff #22] issued BLS, ACLS or PALS certification cards to employees without them doing the test or returning demonstration?" Staff #22 replied, "Negative. I've been doing it with my own equipment. Whenever I do it in the ER, I have to get permission from my operations director. We do skills in the back and there's a test." Staff #22 was asked why the surveyor received conflicting information regarding staff #22 training staff for ACLS. He replied, "Not too sure. Not too sure."
Staff #22 was asked how long staff #22 had been an ACLS instructor. Staff #22 replied, "Since 2012, I've been doing it for years, six". Staff was also asked "do you get recertification?" Staff #22 replied, "I do the ACLS course every 2 years go through region 19, pay the fee, in Las Cruces." Staff #22 was asked who does the training and replied, "[staff #21] in Region 19. I have gone through Las Cruces..."
Staff #22 was asked if he had written tests for employees. Staff #22 replied, "I might have some copies. I'm not too sure. I was laid off from EMS [emergency medical systems] 4 months ago. That's where everything was."

No copies of written tests had been provided to the surveyor by the end of the investigation on 6-6-18.

Facility policy ED 2320.01 titled "Competency" stated, in part:
" ...
IV Policy:
HR [human resources] will maintain the following information on the staff members of the Emergency Department:
" Current license within the state
" Current BLS card
" Current ACLS card
" Current PALS card
..."

The above was confirmed in an interview with the Chief Nursing Officer and other administrative staff the afternoon of 6-6-18.