HospitalInspections.org

Based on a review of facility documentation, a review of personnel files (PF), and staff interview (EMP), it was determined the facility failed to ensure all agency nurses completed mandatory trainings prior to their start dates in the Emergency Department for four of four external agency personnel files reviewed (PF2, PF3, PF4, and PF5).

Findings include:

On April 11, 2023, a review of the facility "UPMC Mandatories for agency staff completion form," revealed, "The following mandatories were completed during orientation at UPMC McKeesport Hospital...All Nurses. Glucometer-FreeStyle Glucose Meter, Age Related-Care and Abuse, Infection Prevention-Clinical Advanced, Patient Education, Partnering for Life, Disability Awareness. Inpatient Nurses Only...Restraints training...."
This document continued to list 11 more mandatory training items for inpatient nurses, one additional training for Emergency Department (ED) nurses, and 14 more mandatory trainings for all employees including agency staff. At the end of the document was a space for the agency nurse to attest and sign that all required education was completed.

On April 11, 2023, a review of the facility procedure that was sent via email from "TempStaffing (Service Account), to EMP 16 titled, "Onboarding Completed by UPMC Travel Staffing," revealed, "Manager Next Steps: Contact Agency Employee: You will receive confirmation from your SNR representative that your employee has cleared to start. Call your employee to welcome them to the unit and provide all reporting instructions. Mandatory Learning Modules: Your agency employee is required to complete mandatory training modules on their first day...Orientation Checklist: It is the unit responsibility to maintain orientation documents for the agency employee just like any new hire. Please use the checklist on Attachment B during the orientation process and partner with your local BU education departments with questions."

On April 11, 2023, a review of PF2 revealed a start date of September 12, 2022. The file contained some screen shots of completed trainings, but not all mandatory trainings were contained in the file. There was no checklist of orientation documents in PF2.

On April 11, 2023, a review of PF3 revealed a start date of January 2, 2023. The file lacked evidence that PF3 had completed the mandatory trainings required. Also, there was no checklist of orientation documents in PF3.

On April 11, 2023, a review of PF4 revealed a start date of December 19, 2022. The file lacked evidence that PF4 had completed the mandatory trainings required. Also, there was no checklist of orientation documents in PF4.

On April 11, 2023, a review of PF5 revealed a start date of February 20, 2023. The file lacked evidence that PF5 had completed the mandatory trainings required. Also, there was no checklist of orientation documents in PF5.

On April 11, 2023, at 1:50 PM, EMP3 provided PFs requested; however, they were incomplete files as evidenced above. During an interview at this time, EMP3 stated that "modules are done at home [by new employees] prior to start date."

On April 11, 2023, at 2:45 PM, EMP16 confirmed, "Our Education [department] starts the process...we need screen shots" to verify the educations were completed.

During an interview on April 11, 2023, at 1:58 PM, EMP14 stated, "it is the unit manager's responsibility" to ensure trainings are completed.