HospitalInspections.org

Based on record review and interview the facility failed to assure that all personnel were licensed and verified as required by regulation. These findings were noted in 4 (#53,54,55,56) out of 4 personnel records reviewed.

Findings: Record review of the facility job description for "Emergency Room Nurse"
no date, stated the qualifciations were as follows:
8+ months of recent working experience as a RN in ER setting, (not including clinicals).
Current unencumbered RN license in state of Texas.
Current BLS &ACLS Card (PALS required for care of adolescents)*
Current TB Screen
Valid Identification/Drivers License

Review of nursing personnel records of staff (#53,54,55,56) revealed that the facility had not verified nurse licensure status with the Texas State Board of Nursing website. The files had no background checks or other pertinent information in the personnel record, inclduing current TB screen or valid identification.

Interview with staff (#58) on 04/11/2024 at 1400, confirmed that the files did not have all the required information for each nurses and began to call the nurses to obtain their resumes and PALS/ACLS cards on his phone.

Based on record review, observation and interview it was determined that the facility failed to ensure that the staff adhered to policies and procedures, creating and unsafe environment for patients.

Findings Include: Record review of hospital policy "Expired Items", revised 07/2023, that was applicable to the emergency services at the facility, stated "To discuss vertification and handling of expried items in the emergency room setting. To ensure all expired items/supplies are removed from service."

Record review of "Medication use process: Dispensing -Emergency Crash Cart Medication System, reviewed 07/2024" stated it is the responsibility of the charge nurse or his/her designee to check the cart/box every 24 hours to ensure the integrity and readiness of the cart/box and its contents.

Observation on 04/11/2024 at 1145 of the ED revealed the crash cart had not been checked on April 1,3,7, and 10.

Inspection and observation of the supplies during the tour on 04/11/2024 at 1150 revealed expired one (1) irrigation kit 4/2023, Seven (7) Broselow Pediatric Resuscitation, IV start kits were expired, 09/2023 One (1) Chest tube insertion tray was expired 12/10/2023, Five (5) Iodoform packing strips were expired-(3) 3/24, (2) 2/2024,
A box of 50 Quick Dipstick Strep A were expired 03/01/2024 A box of 25 Influenza A&B test were expired 02/03/2024.

Interview with the manager (ID#58) during the tour on 04/11/2024 that the items were expired and also stated the crash cart should be checked daily.

Based on observation and interview with staff, the facility failed to post the required signage in the waiting room or in the ambulance entrance of the emergency department.

Findings: Observation with the ED manager (ID#3) on 04/11/2024 at 1045 revealed no EMTALA, Patient Rights signs in the ED waiting room or sexual trafficking sign in the ED bathroom. The EMTALA signs were noted at the registration window.

Interview on 04/11/2024 at 1045 with the ED manager (ID# 58), who was present during the tour, vertified the findings.