HospitalInspections.org

Based on interview and record review of employee files the hospital failed to follow the hospital policy when:
1. Three of seven reviewed employee files had no evidence of yearly evaluations completed.

2. One of seven reviewed employee files had no evidence of yearly abuse training completed.

This failures had the potential to not identify gaps in an employee's skills or knowledge, placing the patients at risk,
and could cause harm to the patients.

Findings:

During a concurrent interview and record review, on 1/16/25 at 1:55 p.m. with the Human Resource (HR) Generalist, employee files for Behavioral Health Associate A (BHA A) was reviewed. The employee file indicated BHA A was hired 11/16/22 and terminated employment 2/5/24, there was no documented evidence that BHA A had an evaluation in 2023. HR stated BHA A should have had an evaluation November or December 2023. Evaluations are done annually during the review period.

During a concurrent interview and record review, on 1/16/25 at 2:05 p.m. with HR, employee files for BHA B was reviewed. The employee file indicated BHA B was hired 2/20/23 and terminated employment 3/28/24, there was no documented evidence that BHA B had an evaluation in 2023. HR confirmed BHA B should have had an evaluation November/December 2023.

During a concurrent interview and record review, on 1/16/25 at 2:32 p.m. with the HR, employee files for BHA C was reviewed. The employee file indicated BHA C was hired 3/2/20 and terminated employment 2/6/24, there was no documented evidence that BHA C had an evaluation since 2020. HR confirmed BHA C should have had an evaluation November/December 2021, 2022, and 2023.

During a concurrent interview and record review, on 1/16/25 at 2:48 p.m. with the HR, employee files for BHA D was reviewed. The employee file indicated BHA D was hired 3/1/21, there was no documented evidence that BHA D had completed abuse training since 10/5/22. HR confirmed BHA D should have completed Abuse training 2023 and 2024.

Review of the Hospital policy, Performance Evaluation Process", revision dated 9/1/22, indicated" ..employees will receive performance evaluations annually during the facility wide review period established by facility management.".

Review of the Hospital's policy, "Abuse and Neglect", last review date 9/22, indicated, "All staff, including medical staff, will receive training on identification of abuse and neglect, and the required reporting requirements and processes. This training will occur as part of the new hire orientation, annually and ongoing as needed based on isolated incidents or trends identified through the Risk Management program.".