HospitalInspections.org

Based on findings from document review and interview, in 1 of 6 personnel files, the facility did not ensure Staff B, a physician, had required training in accordance with New York State law (405.19 (d)(l)(i)(a)). Specifically, Staff B lacked training in Advanced Trauma Life Support (ATLS), Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support (PALS).

Finding include:

-- Per review of personnel file for Staff B, employed since 8/2010, it lacked training certifications for ATLS, ACLS and PALS.

-- During interview with Staff G on 3/24/16 at 2:30 pm, the above findings were acknowledged.

Based on findings from medical record (MR) review, interview and document review, nursing assessments in the ED were not adequate. Specifically, 1) 3 of 3 ED MRs reviewed (chief complaint of abdominal pain), lacked complete abdominal assessment (Patients #1, #2, #3). 2) 3 of 13 ED MRs reviewed lacked fall risk assessments (Patients #1, #4, #5). Additionally 3) the ED lacked a policy and procedure (P&P) that addressed the reassessment of patients after placement in an exam room. There was potential for patient harm and/or injury.

Findings related to (1) above include:

-- Per MR review, Patient #1 was triaged on 12/26/15 at 3:53 am with complaint of urinary frequency, burning urgency and retention. Assessment at 4:05 am revealed, chief complaint of severe abdominal and lower back pain. Nursing assessment lacked documentation regarding gastrointestinal system (e.g., bowel sounds, abdominal distention).

-- Per MR review, Patient #2 was triaged on 3/24/16 at 7:16 am with chief complaint of abdominal pain. Nursing assessment lacked documentation regarding gastrointestinal system (e.g., bowel sounds, abdominal distention).

The same lack of assessment documentation was found in MR for Patient #3.

-- During interview with Staff H on 3/23/15 at 1:15 pm, the above findings were acknowledged.

Findings related to (2) above include:

-- Per MR review, Patient #1 arrived in ED on 12/26/15 at 3:53 am, no fall risk assessment was documented in MR.

The same lack of documentation regarding fall risk assessment was found in MRs for Patient #4 and #5.

-- Per review of the facility P&P titled "Fall Protocol," last revised 1/28/15, it directed ED nursing staff to complete a fall risk assessment on every patient using a modified version of the Morse Fall Assessment.

-- During interview with Staff I on 3/23/15 at 1:30 pm, the above findings were acknowledged.

Findings related to (3) above include:

-- Per review of the facility's ED nursing P&P's, they did not provide evidence that the facility had established procedures regarding reassessment of ED patients within the ED (i.e., not in the waiting room).

-- During interview with Staff H on 3/24/15 at 11:20 am, the above finding was acknowledged.

Based on findings from document review and interview, 2 of 2 personnel files of contracted medical staff (Staff B and Staff J), lacked documentation of complete orientation and/or yearly mandatory training (e.g., patient's rights, advance directives, infection control, fire safety).

Findings include:

-- Per review of personnel file for Staff B, contracted since 3/2011, it lacked documentation of hospital orientation or yearly mandatory training.

-- Per review of personnel file for Staff J, contracted since 8/2015, it lacked documentation of yearly mandatory training in advance directives and patient's rights.

-- During interview with Staff G on 3/24/16 at 2:30 pm, the above findings were acknowledged.