HospitalInspections.org

Based on review of job description policy and procedure, personnel records and interviews, it was determined that the hospital failed to require that 4 out of 4 personnel files did contain documentation of current certification for Basic Life Support ( BLS), Advanced Cardiac Life Support (ACLS), Pediatric Advanced Life Support (PALS), and Neonatal Resuscitation (NRP). This deficient practice poses a risk to a patient's health and safety if the facility cannot confirm that personnel are qualified to perform specific emergency resuscitation measures for different age groups of patients if needed during an emergency situation. (Employees # 3, 18, 22 and 25)

Findings include:

Review of facility job description required staff maintain current certification.

Review of facility policy titled "Credentialing Requirements" HR1332 Version 2.0 reviewed 10/2016, requires: "...Employees shall be solely responsible for maintaining core competency certification in good standing. In the event that the employee has not submitted proof of credential renewal before the expiration date, the employee will be suspended without pay from further employment until such time as the credential is presented to the Unit Manager and Human Resources...."

The following four staff personnel files failed to contain current certification documentation for BLS, ACLS, PALS and NRP per facility policy and procedure.

Employee #3, ICU RN- Expired
Employee #18, ICU RN- Expired
Employee #22, RCP, Cardiac Rehab- Expired
Employee #25, RT, Cath Lab -Expired

The Director of Quality and the ICU/Cath lab director confirmed during interviews conducted 2/24/17 the personnel files did not contain documentation of current certification for BLS, ACLS, PALS, or NRP.

Based on review of policy and procedure, personnel files and staff interview, it was determined that the hospital infection control officer failed to ensure that 5 out of 5 employees had current TB skin testing documented as per facility policy. This deficient practice poses a risk to a patient's health and safety if the facility cannot confirm that personnel are free of TB. (Employees # 4, 18, 28, 29 and 31)

Findings include:

Facility policy and procedure titled "Employee Health Program" HR1374, Version 4.0, revised 2/2015, requires: "...All employees/volunteers will be screened for Tuberculosis at least annually. In the event that the employee has not completed the annual TB test before the expiration date, the employee will be suspended from further employment...."

The following employee files contained no documentation of current evidence of annual Tuberculosis (TB) skin testing:

Employee #4, ICU RN .
Employee #18, ICU RN
Employee #28, ICU RN
Employee #29, ED RN
Employee #31, ICU RN

The Director of Quality confirmed during interview conducted 2/24/17, the personnel files did not contain documentation of current TB skin testing.