The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based on document review and staff interview it was determined the facility failed to ensure 55 of 214, or approximately 26%, of Emergency Department (ED) staff members were in compliance with the facility requirement to complete mandatory annual staff education.

Findings included:

A request to produce evidence of the competencies of the ED staff resulted in receiving documentation of an ED Skills Fair conducted in August 2017. The topics of instruction for Registered Nurses (RNs) included Transfer and Mobility Devices, Restraints, Care for Baker Act Patients, Snake Bites, Trauma Cart, Combat Application Tourniquet, and Dysphagia. The topics of instruction for the ED Techs included Transfer and Mobility Devices, Care for Baker Act Patients, Combat Application Tourniquet, Location of Trauma Cart, and Restraint Application. The Skills Fair consisted of a computer-based education program and a competency demonstration for ED RNs and ED Techs. The documentation included a listing of ED employees indicating 159 had completed the training and 55 ED employees had not.

An interview was conducted with the ED Clinical Education Specialist, the ED Nurse Manager, and the Director of Patient Safety & Risk Management on 6/27/18 at 1:00 p.m. The ED Clinical Education Specialist confirmed 55 of the 214 ED employees had not completed all or some portion of the mandatory annual education by the completion date of December 31, 2017 and continued to be out of compliance with the requirement to the present date. The Nurse Manager indicated all of the 55 employees who had not completed the mandatory annual education continued to be actively at work in the Emergency Department. The Director of Patient Safety & Risk Management confirmed the finding the facility failed to ensure 55 ED staff members were fully qualified to provide services to emergency patients.