HospitalInspections.org

Repeat Deficiency

Based on document review and interviews, the hospital failed to ensure 1 of 606 licensed staff had an active license (Registered Nurse #10).

Finding:

During a previous complaint survey, which was completed on 9/3/2019, it was determined that the hospital failed to ensure three (3) Registered Nurses (RNs) were licensed and one (1) Certified Nursing Assistant was certified as required. As a result the hospital was cited for this failure and was required to submit a plan of correction (POC). The POC, dated 9/18/2019, stated the hospital would be in compliance with this regulation by 11/1/2019.

During this complaint survey, it was determined the hospital failed to meet this regulatory requirement as evidenced by the following:

The "Current Licensure/Certification and Registration" policy, last revised 9/2018, stated, "It is the policy of York Hospital to employ only those individuals who have proper licensure, certification or registration by the appropriate agency in those jobs requiring such status.. License monitoring will be the responsibility of the Leaders... If appropriate documentation is not received by the day of expiration, the staff member will be unable to return to work in the same capacity until licensure has been renewed."

RN #10's professional license expired on 5/23/2020 according to a license verification report.

The RN worked on 5/26/2020 from 7:30 AM to 5:30 PM and 5/27/2020 from 7:45 AM to 5:00 PM according to her timesheet.

The RN's license was not renewed until 5/29/2020; therefore, the RN worked two (2) days without being licensed.

On 8/4/2020 at 1:50 PM, the Director of Quality and Caregiver Experiences confirmed when the hospital's tracking system was implemented on 11/4/2019 and all employee records were manually entered for licensure monitoring; however, RN#10's license information was not loaded into the tracking system.

Based on document reviews and interviews, the hospital failed to ensure staff were certified in Basic Life Support (BLS) for 1 of 10 sampled employees (Nurse Practitioner #6).

Finding:

The 'Emergency Resuscitation Services - Code Blue' policy, dated 5/20/2020, stated "BLS [Basic Life Support] certification is required biannually for physicians, physical therapists, aides, occupational therapists, speech therapists, RTs, home health aides, and all nursing staff with direct patient care assignments".

Nurse Practitioner (NP) #6's BLS certification expired on 3/31/2018. As of 8/4/2020, over two years later, there was no evidence that NP completed BLS certification since her certification expired on 3/31/2018

On 8/4/2020 at 2:04 PM, the Director of Quality and Care Giver Experience confirmed this finding.

Based on document reviews and interview, the facility failed to ensure annual restraint training was completed for 2 of 4 Providers (Provider #2 and Provider #6).

Findings:

The hospital's "'Use of Restraints and Seclusion for Violent/Self-Destructive Behaviors" policy, approved 2/2020, stated: "On-going training and evaluation for competency of the assessment/reassessment, safe use, application and release occurs annually for all staff who applies restraints" and "Providers ordering restraints will receive restraint education and the current policy during Medical Staff Orientation with the Quality & Risk Department. Annual restraint training will be provided through Healthstream or face to face with Education Department to any caregiver responsible for applying restraints".

1. Provider #2 completed restraint training on 3/24/2019 and was due for annual training on 3/24/2020. As of 8/4/2020, there was no evidence of training after 3/24/2020.

2. Provider #6 completed restraint training on 3/19/2019 and was due for annual training on 3/19/2020. As of 8/4/2020, there was no evidence of training after 3/19/2019.

On 8/4/2020 at 2:04 PM., the Director of Quality and Care Giver Experience confirmed this finding.