HospitalInspections.org

Based on interview and record review the facility failed to ensure the director of nursing service provided adequate supervision and evaluation of nursing personnel providing services for two (RN 1 and RN 2) of two sampled agency nursing personnel.

Findings included:

1. Review of the personnel file for RN (Registered Nurse) 1 indicated RN 1 was an agency nurse in the medical telemetry unit who started working in the facility on 12/19/2022. The facility was unable to provide documentary evidence Competency Assessment documentation for RN 1.

2. Review of the personnel file for RN 2 indicated RN 2 was an agency nurse in the intensive care unit who started working in the facility on 10/27/2022. The facility was unable to provide documentary evidence of Competency Assessment documentation for RN 2.

3. Review of facility policy, "Competency Assessment," effective 6/15/2022, indicated "SCOPE:...Contract staff will be held to the same standards as colleagues and the records must be maintained by the business entity. PURPOSE: To define mechanisms used to assess and maintain competency of colleagues as required for the position and by regulatory agencies...Competency: A competency refers to the knoledge, abilities, and behaviours required to perform assigned duties and responsibilities safely and aptly. Competency Assessment: Competency Assessment shall be conducted initially as a part of orientation and an ongoing basis thereafter...Ongong Competency Assessment is an essential process for verifiying an individual's ability to perform their assigned job role by evaluating the ability to apply knowledge, perform skills and demonstrate critical thinking...An individual with the same education and licensure and who has the knowledge, and/or experience for the skills being reveiwed should assess the validation of competency...Competency Assessment documentation should be maintained as part of the "Approved List" in the colleague record..."