HospitalInspections.org

Based on record reviews and interviews, the hospital failed to ensure adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility. This deficient practice was evidenced by failing to ensure emergency department nursing staff were qualified as per their job description for 2 (S2CD, S5RN) of 5 (S2CD, S3RN, S4RN, S5RN, S6RN) RN personnel records reviewed.

Findings:

Review of the job description for registered nurse revealed in part, C. Licenses, Registrations, or Certifications: BLS within 2 weeks of hire. Review of the Addendum for Emergency Department RN attached to the job description revealed in part, please list or describe any additional duties and responsibilities that you perform in your specific position that are not otherwise reflected on this job description. 1.) Current PALS certification at time of hire or within 12 weeks of hire for experienced RNs or completion by the end of the clinical orientation period for new graduate nurses. Maintain certification thereafter. 2.) Current ACLS certification at time of hire or within 12 weeks of hire for experienced RNs or completion by the end of the clinical orientation period for new graduate nurses. Maintain certification thereafter. 3.) Current TNCC and ENPC certification within 12 months of hire for experienced RNs or completion within 18 months of hire for new graduate nurses. Maintain certification thereafter.

Review of S2CD's personnel record revealed a hire date of 09/06/2004. Further review failed to reveal current BLS, ACLS, PALS, or TNCC certifications.

In an interview on 09/19/2024 at 2:30 p.m. S2CD stated he sometimes works as a RN in the emergency department. S2CD verified he does not have current BLS, ACLS, PALS, or TNCC certifications. S1CNO stated S2CD's job description only requires him to have current BLS due to him being the ED Clinical Director. When asked if all RNs that work in the emergency department are required to have current BLS, ACLS, PALS, and TNCC certifications, S1CNO stated yes. When asked if S2CD is working in the emergency department as a RN should he be required to have the above stated certifications as do all other RNs working in the emergency department, S1CNO stated well when presented like that, then yes.

Review of S5RN's personnel record revealed a hire date of 09/16/2019. Further review failed to reveal a current TNCC certification.

In an interview on 09/19/2024 at 3:12 p.m. S2CD verified there was no documentation of current TNCC certification in S5RN's personnel record.