HospitalInspections.org

UNLICENSED ASSISTIVE PERSONS (UAPs)

1. Based on review of personnel files, review of the North Dakota Administrative Code (NDAC), and staff interview, the Critical Access Hospital (CAH) failed to comply with federal and state regulations to ensure current registration with the North Dakota Board of Nursing (NDBON) for 1 of 1 surgical technician (Staff Member #1) personnel file reviewed. Failure to ensure UAPs registered with the NDBON limited the CAH's ability to ensure staff were qualified to assist with patient care/procedures.

Findings include:

The NDAC 54-01-03-01 stated, ". . . 'Technician' means an unlicensed assistive person who may perform limited nursing functions within the ordinary, customary, and usual roles in the person's field. Examples may include surgical and dialysis technicians and medical assistants. . . . 54-07-02-02.1. Unlicensed assistive person registry status. Unlicensed assistive persons who carry out delegated nursing interventions must hold current registry status either on the board registry or on another state registry recognized by the board. . . ."

Review of eight randomly selected personnel files occurred on the afternoon of 10/25/23. Staff Member #1 worked in the surgical department as a surgical technician. Staff Member #1's file lacked evidence of registration as a UAP with the NDBON.

During an interview on 10/26/23 at 11:20 a.m., a human resources staff member (#3) confirmed Staff Member #1 failed to provide evidence of registeration as a UAP with the NDBON.

ADVANCED CARDIAC LIFE SUPPORT (ACLS)

2. Based on review of personnel files, review of job descriptions, and staff interview, the Critical Access Hospital (CAH) failed to ensure all nursing staff possessed the adequate qualifications, training, and education related to their specific roles within the CAH for 1 of 1 cardiopulmonary rehabilitation nurse (Staff Member #2) personnel file reviewed. Failure to ensure staff working in the Cardiopulmonary Rehabilitation Department obtained ACLS certification limited the CAH's ability to ensure staff were qualified to provide proper patient care during an emergency.

Findings include:

- Review of the "Cardiopulmonary Rehabilitation Technician Job Description" occurred on the afternoon of 10/26/23. This job description, revised 11/08/22, stated, ". . . QUALIFICATIONS: RN [Registered Nurse] or LPN [Licensed Practical Nurse] with Current ND [North Dakota] license or Exercise Physiologist with Bachelor of Science Degree, CPR [Cardiopulmonary Resuscitation] Certified, ACLS Certified. . . ."

Review of eight randomly selected personnel files occurred on the afternoon of 10/25/23. Staff Member #2 worked in the Cardiopulmonary Rehabilitation Department. Staff Member #2's file lacked evidence of ACLS certification.

During an interview on 10/26/23 at 11:20 a.m., a human resources staff member (#3) confirmed Staff Member #2 failed to provide evidence of ACLS certification.

Based on policy review, document review, meeting minutes review, and staff interview, the Critical Access Hospital (CAH) failed to evaluate services furnished under contracts for 1 of 1 year reviewed (October 2022 - September 2023). Failure to evaluate services furnished by contractors limited the CAH's ability to ensure the contractors provided quality services for the CAH and its patients.

Findings include:

Review of the policy "CQI [Continuous Quality Improvement] - Quality Assurance" occurred on 10/25/23. This policy, effective 04/05/21, stated, "Purpose: To provide high quality patient care through a systematic, ongoing, concurrent monitoring method, thereby identifying problems or potential problems, and, through the evaluation of data collected, tracking sources and effecting resolutions. . . . Annually: . . . . A contract review will also be undertaken annually. . . ."

Review of the CAH's list of contracted services occurred on 10/26/23. This undated list showed approximately fifty contractors provided direct and indirect patient care services at the CAH.

Reviewed on October 24-26, 2023, the medical staff and CQI-QA [Quality Assurance] meeting minutes from September 2022 through October 2023 failed to include evidence CAH staff evaluated contracted services.

Upon request on 10/26/23, the CAH failed to provide evidence staff evaluated contracted services in the past year to ensure the contractors provided quality services for the CAH and its patients.

During interview on 10/26/23 at 10:20 a.m., an administrative staff member (#4) confirmed the CAH failed to document the evaluation of contracted services in the past year.