HospitalInspections.org

Based on document review and interview, the facility failed to ensure staff were assigned the appropriate job description in 1 of 10 (S4, Patient Support Technician and Tech in Surgery, Certified) personnel files reviewed.

Findings Include:

1. Review of the Indiana Code indicated the following:
a. IC 25-36.1-1-1 titled Certified surgical technologist indicated
Sec. 1. An individual may not:
(1) profess to be a certified surgical technologist; or
(2) use the initials "CST" or any other words, letters, abbreviations, or insignia indicating or implying that the individual is a certified surgical technologist; unless the individual holds and maintains the Certified Surgical Technologist Credential administered by the National Board of Surgical Technology and Surgical Assisting (NBSTSA). As added by P.L.36-2007, SEC.1.
b. IC 25-36.1-2-5 Requirements to practice surgical technology in a health care facility
Sec. 5. (a) Except as provided in section 4 of this chapter, an individual may not practice surgical technology in a health care facility unless the individual meets one (1) of the following requirements:
(1) Is certified under IC 25-36.1-1.
(2) Has completed a surgical technology program provided by the United States Army, Navy, Air Force, Marine Corps, or Coast Guard, or the commissioned corps of the United States Public Health Service.
(3) Provides evidence to the health care facility that the individual was employed to practice surgical technology in a health care facility before July 1, 2009.
(4) Is performing duties related to the individual's employment by the federal government.
(5) Is practicing surgical technology during the twelve (12) month period immediately following the completion of a degree from an accredited school of surgical technology.
(6) Has the appropriate abilities, as determined by the health care facility.
(b) An individual who is:
(1) described in subsection (a)(1), (a)(2), or (a)(3); and
(2) practicing surgical technology in a health care facility; annually shall complete fifteen (15) hours of continuing education concerning surgical technology in order to continue practicing surgical technology.
(c) An individual who wants to practice surgical technology in a health care facility is responsible for establishing to the satisfaction of the health care facility that the individual has complied with this section.
(d) An individual practicing surgical technology in a health care facility is responsible for immediately notifying in writing the governing body of the health care facility, or the governing body's designee, of any changes in the individual's compliance with this section.
(e) A health care facility shall maintain copies of any written documentation provided by the individual to the health care facility under subsection (c) or (d) to show compliance with this section.
(f) This chapter does not require a health care facility to permit an individual described in subsection (a) to perform surgical technology services at the health care facility.
As added by P.L.97-2009, SEC.1.

2. Document review of job description for job title Surgical Technologist PST (Patient Care Tech) Cert indicated the following:
a. Education requirements included a 2 year associate degree completion of surgical technology program. Graduation from a CAAHEP or ABHES accredited program, as well as have a GED or high school diploma. Graduates of a Military Training Program in Surgical Technology; complete a program that has not yet received, in the process of receiving, or has received CAAHEP accreditation, as well as provide a copy of DD214 stating the base where ethe program was completed, a graduation certification. (Required)
b. Certification requirements within six (6) months from hire certifications/licensures: (Certified Surgical Technologist (CST) obtained by NBSTSA).

3. Document review of S4's personnel file indicated the following:
a. S4 was hired in June of 2024 and assigned a job description job titled Surgical Technologist PST cert.
b. S4's personnel file lacked documentation that S4 met the education requirements of the job description and the requirements of Indiana Code IC 25-36.1-1-1.

4. Interview A6 (Hospital Administrator, Chief Nurse Executive), A7 (Director of Quality), and A10 (Human Resources Director) on 05/20/2025 at approximately at 4:45 p.m. each confirmed that S4 was given the incorrect job description upon hire as S4 did not meet the qualifications, an internal investigation was initiated in August 2024, and the resolution was creating a new job description was assigned to S4 in March of 2025.