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Tag No.: A0145
Based on document review and interview, it was determined that for 4 of 8 (E #4, E #5, E #6, and E #7) personnel files reviewed for abuse, neglect, mandatory reporter training; the Hospital failed to ensure patients right to be free from all forms of abuse by providing abuse training to all staff. This has the potential to affect all patients served at the facility, with a current census of 193.
Findings include:
1. On 2-24-22 at approximately 1:00 PM, the Hospital's policy titled, "Contracted Staff/Traveler (Clinical) Screening & Vaccination Requirements" dated 2021 was reviewed. The policy required, "Category: State Specific, State Specific Requirements: Requirements collected as applicable by state (State specific Mandatory Reporter, Fingerprinting, Certification, health requirement, etc." b.) The Hospital's course curriculum titled, "New Hire Courses-Quad Cities" Received by Risk Manager E#2 was reviewed. The Course Curriculum lists: "*Illinois Adult with Disabilities and Elder Adult abuse and Neglect Mandatory Reporter Training, *Illinois DCFS Child Abuse Mandatory Reporting Training, *A2:A30IA Mandatory Reporter Abuse Training" as requirements before eligible work status is granted.
2. On 2-24-22 at approximately 12:30 PM, the personnel files for 4 Registered [Travel] Nurses (E #4, E #5, E #6, and E #7), were reviewed. The personnel files for E #4, E #5, E #6 and, E #7 lacked documentation of any Abuse, Neglect, Mandatory Reporter training.
3. On 2-24-22 at approximately 12:20 PM, an interview was conducted with HR Business Partner's (E#8 and E#9). E#8 stated, "employees are required to have abuse training during new employee orientation and every three (3) years. E #9 stated that "E #4, E#5, E#6, and E#7 are travel nurses and should have had it but they did not have any record of the training in their system." The Hospital did not provide documentation of abuse training for E #4, E #5, E #6 and E #7.