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Based on review of personnel files, review of schedules, review of position descriptions, review of policies and procedures and interviews with key staff on August 24, 2010, it was determined that the hospital failed to ensure that all CAH nursing staff and non-CAH nursing staff were adequately oriented and trained.

Findings include:

1. The Down East Community Hospital Position Title: Emergency Department Staff Registered Nurse stated, "Requirements:...ACLS [Advanced Cardiac Life Support] mandatory."

2. Three (3) personnel files of Emergency Department Registered Nurses were reviewed. One (1) personnel file did not contain documentation that the Registered Nurse D had completed ACLS training.

3. During an interview with the Human Resources Director on August 24, 2010, he/she stated that Registered Nurse D had transferred from the Emergency Department to the Medical/Surgical Unit in May 2010 and ACLS was not mandatory on that unit.

4. A review of the actual staffing schedule for the Emergency Department on August 24, 2010 revealed that Registered Nurse D was off orientation on March 12, 2010 and worked independently in that department from March 17 through May 7, 2010.

5. These findings were confirmed by the Human Resources Director on August 24, 2010.

6. During a telephone interview with the Emergency Department Nurse Manager on Augsut 25, 2010, he/she stated that Registered Nurse D had been hired prior to him/her taking the current position. He/she added that it was his/her understanding that ACLS was mandatory before someone was hired to work in the Emergency Department.

7. The Down East Community Hospital policy titled ' Employee Education' stated, " Education Day will be scheduled on a quarterly basis. New regular full time and part time employees will attend Education Day at the first opportunity following their date if hire." This policy did not require that non-employees attend the Education Day.

8. A review of the personnel file of Registered Nurse B on August 24, 2010 revealed that there was no documentation that this staff nurse had completed an orientation.

9. A review of information provided on August 24, 2010 by the Chief Nursing Officer revealed that an Education Day was held on August 5, 2010 and Registered Nurse B was not listed as an attendee.

Based on document review and interview swith key personnel on August 24, 2010, it was determined that the hospital failed to maintain clinical records in accordance with their policies and procedures in 12 (twelve) of twenty-one (21) medical records. (RECORDS: A, B, C, E, F, I, K, L, N, P, Q and R)

Findings include:

1. The hospital " Medical Record Completion " policy states, " all entries must be legible and complete ...authenticated, dated, and timed promptly by the person who is responsible for ordering, providing or evaluating the service provided " , and " the Emergency Room Medical record must be completed at the time of the patient ' s visit to include ....diagnostic and therapeutic orders, documentation of findings and assessments ....the condition and disposition of patient on release ... "

2. The " Emergency Department Physician Assessment and Orders " form in Record A, dated May 31, 2010, failed to contain documentation of the time of the order.

3. The " Emergency Department Physician Assessment and Orders " form in Record B, dated February 28, 2010, failed to contain documentation of the physician's signature, time, discharge diagnosis, discharge condition, and disposition.

4. The " Emergency Department Physician Assessment and Orders " form in Record C, dated June 27, 2010, failed to contain documentation of the time and discharge condition.

5. The " Emergency Department Physician Assessment and Orders " form in Record E, dated May 26, 2010, failed to contain documentation of the time, discharge condition, and disposition.

6. The " Emergency Department Physician Assessment and Orders " form in Record F, dated February 18, 2010, failed to contain documentation of the time, discharge diagnosis, discharge condition, and disposition.

7. The " Emergency Department Physician Assessment and Orders " form in Record I, dated June 29, 2010, failed to contain documentation of the time, discharge diagnosis, discharge condition, and disposition.

8. The " Emergency Department Physician Assessment and Orders " form in Record K, dated June 30, 2010, failed to contain documentation of the time, discharge diagnosis, discharge condition, and disposition.

9. The " Emergency Department Physician Assessment and Orders " form in Record L, dated May 22, 2010, failed to contain documentation of the time, discharge diagnosis, discharge condition, and disposition.

10. The " Emergency Department Physician Assessment and Orders " form in Record N, dated June 10, 2010, failed to contain documentation of the time, discharge condition, and disposition.

11. The " Emergency Department Physician Assessment and Orders " form in Record P, dated June 7, 2010, contained documentation of the time as being " 0 " and failed to document the discharge condition.

12. The Emergency Room note, dictated on April 18, 2010, failed to contain documentation of the physician ' s signature as of August 24, 2010 in Record Q.

13. The " Emergency Department Physician Assessment and Orders " form in Record R, dated March 8, 2010, failed to contain documentation of the discharge condition, and disposition.

14. These findings were confirmed with the Clinical Director of Nursing Services on August 24, 2010.