HospitalInspections.org

Based on record reviews and interview, the hospital failed to ensure personnel met applicable standards required by State regulations for hospital personnel as evidenced by failure to have documented evidence of a check/review of the Louisiana Department of Health and Hospital's "Louisiana State Adverse Actions List Search" every 6 months after the initial search on hire for 3 of 3( S2BHA, S3DA, S4DAT/PA) personnel file reviewed from a sample of 10(S1DHR, S2BHA, S3DA, S4DAT/PA, S5IC, S6DON, S7RN, S8RN, S9RN, S10IC) ) personnel files reviewed.
Findings:

Review of the Louisiana Department of Health and Hospital's "Louisiana State Adverse Actions List Search" revealed, in part, "Employers must use the DSW registry to determine if there is a finding that a prospective hire has abused or neglected an individual being supported, or misappropriated the individual 's property or funds. If there is such a finding on the registry, the prospective employee shall not be hired.
The provider shall check the registry every six months to determine if any currently employed direct service worker or trainee has been placed on the registry with a finding that he/she has abused or neglected an individual being supported or misappropriated the individual 's property or funds."


Review of the personnel files for S2BHA with a a hire date of 3/06/18, S3DA with a hire date of 7/01/17, and S4DAT/PA with a hire date of 7/04/17 revealed the DSW registry was checked at the time of their hire. Further review revealed no documented evidence the registry was checked every 6 months after their hire dates. No documentation of a registry review post date of hire was found.

In an interview 3/7/19 10:45 a.m. S4DHR confirmed a check of the DSW adverse action registry was not done again and every 6 months after hire on unlicensed personnel providing direct care to patients. She confirmed no check of the registry was done only at the time of hire for S2BHA, S3DA, and S4DAT/PA . She reported it was not part of the facility's process to check the Adverse Actions List Search website after the initial review and every 6 months thereafter for each unlicensed personnel.