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Based on interview and record review, the facility failed to ensure travel nurses competencies were evaluated according to facility policy when one of four sampled nursing staff (RN 1, Registered Nurse 1) did not complete unit specific annual competencies for over three years.

This failure resulted in the facility not ensuring travel nurses were competent to provide care to patients.

Findings:

During a concurrent interview and record review on 11/21/24, at 2:40 p.m., with Nursing Director of Labor and Delivery (NDLD), RN 1's employee competency record was reviewed. NDLD stated RN 1 was a travel nurse and had been working consecutive travel contracts in the Labor and Delivery (LD, unit which babies are born) unit since 2021. NDLD stated RN 1's initial LD unit competency evaluation was completed on 10/2021. NDLD indicated RN 1 did not have annual competency evaluations since that initial evaluation. NDLD stated nursing staff directly hired by the facility were required to have annual competency evaluation but was unsure if the policy applied to travel nurses.

During an interview on 11/21/24, at 3:20 p.m., with RN 1, RN 1 stated they did not participate in annual LD unit competency evaluations. RN 1 stated they had worked at the facility since 2021 in the LD department. RN 1 stated they had completed online education provided by their travel agency, but did not include hands on demonstration of skills.

During a concurrent interview and record review on 11/21/24, at 3:50 p.m., Clinical Manager (CM), CM stated nursing staff were required to complete two types of competency evaluations an annual hospital wide and unit specific competency evaluation. CM stated they had not personally performed any unit specific competencies evaluations for RN 1. CM stated review of unit records did not indicate RN 1 had completed LD unit competencies other than an initial evaluation in 10/2021. CM stated RN 1's travel agency had online continuing education which RN 1 had completed but did not know if the continuing education conformed with LD unit competencies.

During an interview on 11/21/24, at 4:20 p.m., with human resources vice president (HRVP), HRVP stated the facility did not have policy or current practice to ensure annual unit specific competency evaluations for travel nurses were completed.

During a record review of RN 1's travel contract record, indicated RN 1 worked five contracts with the facility in the LD department during the following dates:
1. 10/29/23 to 2/10/24,
2. 2/28/24 to 6/1/24,
3. 6/19/24 to 7/20/24,
4. 8/15/24 to 9/14/24,
5. 10/27/24 to 2/8/25.

During a record review of a sample facility competency assessment titled, "Department Competency Assessment: Labor and Delivery Registered Nurse," undated, the sample competency assessment indicated demonstration of skills such as: "demonstrate how to connect fetal monitor(device to monitor fetal heart rate)...demonstrate proper set-up and location of infant transport warmer (device to maintain newborn temperature) in Main OR ...demonstrate calculation of Quantitative Blood Loss (QBL) and Cumulative QBL Total."

During a review of facility policy and procedure (P&P) titled, "Temporary Staff from Outside Agencies Policy," dated 4/21/2020, the P&P indicated "the department is accountable for verifying that an evaluation of competency has been documented on all agency staff if required for accreditation ...the manager should evaluate the assignment every six months."

During a review of facility P&P titled, "Competency Assessment - Nursing Staff," dated 5/16/2024, the P&P indicated the policy was intended to "ensure that staff are competent to provide nursing care to patients ...annual competency evaluation will be carried out by the Nurse manager and/or nurse educator(s). Annual core and unit specific competencies will be identified by the following: Performance Improvement Activities, Educational Needs Assessment, New Advances in Technologies, State Requirements, Joint Commission Requirements, Federal Requirements, High Risk, Low Volume and Problem Prone Areas."