HospitalInspections.org

34756



Based on staff interview, a review of the POC (Plan of Correction) and credible evidence presented by hospital staff, it was determined hospital staff had failed to fully implement all components of the POC.

The findings include:

On 7/15/20 at 11:30 AM, the surveyor requested evidence of education in infection control provided to clinical staff as stated in the hospital's POC for a survey ending 2/21/20. While reviewing the documentation and comparing the list of staff who had received training with the provided list of personnel, it was noted all clinical personnel had not completed the training. The surveyor discussed the finding with Staff Member (SM) #3 and asked to be provided with departmental personnel rosters and training documentation. After reviewing the documentation SM #3 informed the surveyor that overall compliance was 73% when PRN (as needed) staff were included and 77% without PRN staff included. On 7/16/20 SM #3 informed the surveyor that an additional 68 (sixty-eight) staff members had received the training bringing the compliance up to 80% including PRN staff and 87% when PRN staff were excluded.

SM #3 informed the surveyor that there were several options used to provide training to staff, to include on-line and the use of a secure smart phone app. Prior to exit on 7/16/20, the surveyor discussed the findings with the management team and shared the concern that even with multiple platforms in use to provide training there seems to be a fault in the process that allowed a significant number of personnel to miss the training. There were no questions, comments or further information provided to the surveyor.