HospitalInspections.org

Based on document review and policy review, Emergency Department staff did not receive facility required training to meet the anticipated needs of the department, specifically:
1.) 1 of 4 Registered Nurses did not have current ACLS training.
2.) 3 of 4 Medical/midlevel practitioners did not have evidence they received EMTALA (Emergency Medical Treatment and Active Labor Act) training.

Findings for #1:

Review on 7/28/15 of the personnel file for Staff # 4, ED RN revealed the following:
- The facility's competency assessment tool, attachment B signed off by the ED manager on 3/19/15 indicates ACLS (advanced cardiac life support) recertification is to be completed bi-annually. " 2011 " is listed as the competency completion date.
- No evidence of current ACLS training was found in the record.

Review on 7/28/15 of policy " Minimum Annual Mandatory Review and/or other Requirements " last revised 12/13 revealed current compliance in ACLS training is required for Emergency Department staff.

Review on 7/29/15 of the email received from Staff # 13, Manager of Regulatory Affairs and QI confirmed Staff #4, ED RN does not have current ACLS training.

Findings for #2:

Review on 7/28/15 of the credential files for Staff # 5, 6 and 8 revealed no evidence of EMTALA training.

Review on 7/29/15 of policy " Minimum Annual Mandatory Review and/or other Requirements " last revised 12/13 revealed EMTALA training is required for all staff.

These findings were verified on 7/29/15 by Staff # 13.