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No Description Available
Tag No.: C0154
Based on job description, Personnel Record review and staff interview, the hospital failed to ensure that 1 of 3 registered nurses (RN #1) maintained current Basic Life Support/Basic Cardiac Life Support and Advanced Cardiac Life Support (BLS/BCLS, ACLS) as required by job description for RNs in the emergency room(ER) for 1 of 3 RN personnel files reviewed.
The findings include:
1. Review on 03/15/2017 of Job Description: ER Registered Nurse under "Other Essential Duties and Responsibilities" revealed "current BLS/BCLS, ACLS" as an essential duty and responsibility.
2. Review on 03/15/2017 of personal record of RN #1 revealed BLS/BCLS expired 08/27/2015. No record of current or expired ACLS found.
3. Interview with Administrative Personnel #2 (AP #2) on 03/15/2017 at 1630 confirmed that RN #1 had not renewed BLS/BCLS as required by job description. Interview revealed there was no ACLS certification completed as required. Interview confirmed RN#1 had worked in the emergency department in the past seven months without current certification in BLS/BCLS and ACLS.
No Description Available
Tag No.: C0204
Based on policy and procedure review, Directions for Use (DFU), observation and staff interview, the hospital failed to ensure that preventative maintenance (PM) was done for 2 of 2 defibrillators located in the hospital's emergency department.
The findings include:
Review on 03/15/2017 of the hospital's policy and procedure, revealed that there is no policy and procedure for preventative maintenance for defibrillators in the hospital.
1. Observation on 03/15/2017 of Lifepack12 Defibrillator in Trauma 1 revealed a sticker indicating last inspection on 6/15 with 'Next Due" on 6/16 (nine months past due).
Review on 03/15/2017 of Directions for Use (DFU) for Lifepack12 Defibrillator/Monitor Operating instructions "Maintaining the Equipment, General Maintenance and Testing", "Additional Periodic maintenance and testing-such as electrical safety tests, performance inspection and required calibration-should be performed regularly by qualified service technicians".
Interview with Administrative Personnel #1 (AP#1) on 03/15/2017 at 1340 revealed " ...calibration should be done yearly ...last done on 06/2015". "I will call biomed today". AP #1 confirmed that there is not a policy for PM on equipment.
2. Observation on 03/15/2017 of CodeMaster XL+ Defibrillator in Trauma 2 observed sticker indicating last inspection on 6/15 with 'Next Due" on 6/16 (nine months past due).
Review on 03/15/2017 of Directions for Use (DFU) for CodeMaster XL+ Defibrillator Performance Verification should 'Verify the performance of the defibrillator every 6 months and after servicing". Defibrillator calibration indicates that "The defibrillator should be recalibrated ... after each scheduled preventative maintenance".
Interview with Administrative Personnel #1 (AP #1) on 03/15/2017 at 1340 AP#1 stated that " ...calibration should be done yearly ... last done on 6/2016". "I will call biomed today". AP #1 confirmed that there is not a policy for PM on equipment.
NC00124217