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Based on interview and document review, the hospital failed to ensure that emergency department physicians maintain documentation of current advanced cardiac life support (ACLS) certification.

Failure to ensure that physicians maintain current ACLS certification places patients at risk for poor health outcomes, injury, and death.

Findings included:

1. The hospital failed to ensure that all emergency department physicians maintained current ACLS for 1 of 1 emergency department physicians.

Cross reference: Tag A-2406

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Based on interview, document review, and review of hospital medical staff rules and regulations, the hospital failed to ensure that emergency department physicians maintain documentation of current advanced cardiac life support (ACLS) certification.

Failure to ensure that hospital providers maintain current ACLS certification places patients at risk for poor health care outcomes, injury, and death.

Reference: 42 CFR 482.55(b)(2) - "The medical staff must establish criteria, in accordance with State law and regulations and acceptable standards of practice delineating the qualifications required for each category of emergency services staff (e.g., emergency physicians, specialist MD/DO, RNs, EMTs, mid-level practitioners, etc.)."

Findings included:

1. Review of the hospital's Medical Staff Bylaws and Medical Staff Rules and Regulations, adopted 10/24/19, showed that emergency department (ED) physicians were required to maintain documentation regarding current ACLS certification.

2. On 10/30/20 at 10:30 AM, the investigator reviewed the personnel file of one ED physician (Staff #2) with the Medical Staff Services Coordinator (Staff #3). Document review showed that the file did not contain a current copy of the provider's ACLS certification.

3. On 10/30/20 at 12:15 PM staff #3 confirmed the investigator's finding that the ED physician did not have current ACLS certification. Staff #3 stated that the provider's delineation of privileges did not state that ED physicians were required to maintain ACLS certification, but the medical staff rules and regulations did specify that ACLS certification was a requirement for ED physicians.