HospitalInspections.org

Based on a review of credentialing files, the govening body was not responsible for all services furnished in the hospital, whether or not they were furnished under contracts.

Findings were:

A review of Facility Trauma Designation criteria revealed the following:
Basic (Level IV) Trauma Facility Criteria Checklist
B. PHYSICIAN SERVICES - An Emergency Medicine board-certified physician who is providing trauma coverage shall have successfully completed an ATLS Student Course or a DSHS-approved ATLS equivalent course.

Current ATLS verification is required for all physicians who work in the ED and are not board certified in Emergency Medicine.

A review of the credentialing files for 8 EmCare physicians (staff #1, #10, #11, #12, #13, #14, #15 and #16) revealed that 3 of 8 physicians (staff #1, #14 & #16) did not possess current ATLS certification.

The above was confirmed in an interview with the Chief Executive Officer and the Director of Nursing on the afternoon of 4-10-14 in the facility conference room.

Based on a review of documentation and an interview with staff, the facility did not require appropriate staff to have education, training and demonstrated knowledge in the use of cardiopulmonary resuscitation, including required periodic recertification.

Findings were:

Review of employee personnel files on 4/9/14 revealed 1 of 2 Licensed Vocational Nurses (staff #2) did not have current Cardiopulmonary Resuscitation (CPR).

The above was confirmed in a meeting with the Chief Executive Officer and Director of Nursing on the afternoon of 3-19-14 in the facility Center conference room.