103.4 Functions
The governing body, with technical
assistance and advice from the
hospital staff, shall do the
following:
(1) Provide appropriate physical
resources and personnel required to
meet the needs of the patients and
participate in planning to meet the
health needs of the patients and
health needs of the community. A
quality control mechanism should be
established which includes as an
integral part thereof a risk
management component and an infection
control program.
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Observations:
Based on review of facility documents and interview with staff (EMP) it was determined that the facility failed to provide adequate personnel to provide patient care for the Surgical Services department.
Findings include:
Review on May 14, 2024, of facility document " Scope of Services " , no date, revealed " ...The Operation Room and PACU [Post Anesthesia Care Unit] renders interdisciplinary perioperative nursing care at all times ...Hours of operation are 7:00 AM to 3:30 PM, and twenty-four-hour coverage is maintained by assigning an " on-call " team after hours, weekends, and holidays ... "
Review on May 14, 2024, of facility document " On Call Guidelines, Surgical Services " , reviewed January 20, 2021, revealed " ...Call hours may vary from weekday to weekend, to holiday coverage based on the needs of the operating units. After normal hours of operation, on call provides coverage 24 hours a day, 7 days a week ... "
Review on May 14, 2024, of facility document " OR Call Schedule " , dated January 2024 through May 14, 2024, revealed the facility lacked OR staff to cover on-call hours occurring outside the hours of operation of 7:00 AM to 3:30 PM, on weekends, and holidays on sixty-seven (67) occurrences. The dates involved are as follows:
January 6, 2024
January 7, 2024
January 8, 2024
January 9, 2024
January 10, 2024
January 13, 2024
January 14, 2024
January 15, 2024
January 17, 2024
January 18, 2024
January 22, 2024
January 24, 2024
January 26, 2024
January 28, 2024
January 29, 2024
January 31, 2024
February 2, 2024
February 5, 2024
February 7, 2024
February 9, 2024
February 12, 2024
February 13, 2024
February 15, 2024
February 16, 2024
February 17, 2024
February 18, 2024
February 24, 2024
February 25, 2024
February 26, 2024
March 1, 2024
March 4, 2024
March 5, 2024
March 8, 2024
March 12, 2024
March 13, 2024
March 15, 2024
March 16, 2024
March 17, 2024
March 18, 2024
March 19, 2024
March 20, 2024
March 22, 2024
March 23, 2024
March 24, 2024
March 25, 2024
April 4, 2024
April 6, 2024
April 7, 2024
April 8, 2024
April 15, 2024
April 17, 2024
April 19, 2024
April 20, 2024
April 21, 2024
April 22, 2024
April 25, 2024
April 26, 2024
April 27, 2024
April 28, 2024
April 29, 2024
May 2, 2024
May 3, 2024
May 4, 2024
May 5, 2024
May 6, 2024
May 10, 2024
May 13, 2024
Interview with EMP1 on May 14, 2024, at 10:45 AM, revealed that when the OR does not have one registered nurse and one surgical technologist to cover on-call hours, the OR goes on divert status. Further interview with EMP1 confirmed the facility did not have on-call coverage on the above dates.
| | Plan of Correction - To be completed: 06/03/2024
WHO
The Chief Nursing Officer is responsible for the corrective action and overall ongoing compliance.
WHAT
The following actions have been taken:
1.In an effort to fill vacant Perioperative Nurses (OR RN) and Certified Scrub Tech (CST) positions, the Department of Human Resources- Talent Acquisition has posted vacant positions on the organization's website Careers section, as well as on social media and job search websites. They have also held Walk-In Wednesdays job fairs on site. There is a sign-on bonus offering for OR RNs.
- Since January 2024, we have had 4 OR RN Candidates offered employment, 2 accepted, 1 accepted then dropped out during on-boarding, and 1 declined offer due to salary. We had 3 applicants for Certified Scrub Tech, 1 was hired, 2 declined to be interviewed. We have had 2 applicants for the OR Tech position, both declined interviews due to salary and call requirements.
- As of June 3, 2024, the OR RN who accepted will have completed her on-boarding and will be eligible to take on-call time thereby decreasing the frequency of the facility's need to divert.
WHEN
With the RN completing the onboarding, we expect to have full on-call coverage, 6/3/24.
How
Ongoing compliance will be sustained by:
1. monitoring OR on-call schedule
2. reporting any lack of on-call coverage as Infrastructure Failure.
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