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Based on interview and personnel file review the facility failed to ensure eight (Staff S, T, U, V, W, X, Y and Z) of eight non-employee (agency) nursing staff had signed job descriptions, Electronic Disqualification List (EDL, a listing of individuals who have been determined to have abused or neglected a patient; misappropriated funds or property belonging to a patient; or falsified documentation verifying delivery of services to a patient) checks before hire and periodically, evidence of restraint (any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to freely move his or her arms, legs, body or head) training or first aide in restraint training (the first aid techniques used to address common emergencies that can occur from the use of restraint and seclusion) and evidence of periodic performance evaluations. The lack of these checks and training before hire and periodically had the potential to affect the care and safety of all patients in this facility. The facility census was 117 with 25 patients in Ward H, the Medicare Psychiatric Unit.

Findings included:

1. Even though requested, the facility failed to provide a policy regarding the required criteria for hiring non-employee (agency) nursing staff that included initial background checks, initial and periodic EDL checks, required restraint training, or job performance evaluations to ensure the safety and care of their patients.

2. Record review of the facility's report titled, "Agency Nurses," dated 10/27/16, showed that all eight agency nurses had been scheduled and worked a total of 95 12-hour shifts in the last seven months.

3. Record review of Staff S's personnel file contained no hire date but showed she was a Registered Nurse (RN) hired through an employment agency. The facility failed to provide evidence that Staff S had:
- An EDL prior to hire or periodically;
- A signed job description;
- Periodic evaluation of her clinical skills or the care she provided to patients;
- Restraint training; or
- First Aid in Restraint Training.

4. Record review of Staff T's personnel file contained no hire date but showed she was an RN hired through an employment agency. The facility failed to provide evidence that Staff T had:
- An EDL prior to hire or periodically;
- A background check to rule out any criminal acts;
- A signed job description;
- Periodic evaluation of her clinical skills or the care she provided to patients;
- Restraint training; or
- First Aid in Restraint Training.

During an interview on 10/27/16 at 9:05 AM, Staff Q, Human Resources Director, stated that he knew that none of the agency nurses would have EDL information in their personnel files.

5. Staff Q's review record review on 10/27/16 of the agency nurse personnel files showed:
- No agency nurses had EDL's prior to hire in their personnel files;
- Only two agency nurses had verification letters of previous employment; and
- Agency Nurse, Staff W, did not have evidence of a background check.

During an interview on 10/27/16 at 9:25 AM, Staff B, Chief Nursing Executive (CNE), stated that she was surprised that the agency nurses personnel files had deficient documentation.