HospitalInspections.org

Based on staff interviews and facility document reviews the Chief Executive Officer failed to ensure that 5 of 17 (#4, #13, #15, #16 and #17) employees records reviewed had cleared background checks prior to working with patients, failed to ensured that there was at least one inpatient Registered Nurse coverage provided 24 hours a day, and that annual Radiology equipment preventive maintenance is performed.

Findings

1. Review of 17 staff records revealed that staff (#4, 13, 15, 16 and 17) revealed that records did not contain completed background screenings.

Interview conducted with the Human Resource Manager on 3/21/12 at approximately 3:00 PM revealed that each of the identified staff members are currently working at the facility, and have contact with patients on a daily basis. Further interview with the Human Resource Manager on the same date and time revealed that there are no completed background screenings on the identified staff. Human Resource Manager further added that some of the screenings may not be done due to the account not being paid by the facility, and the screenings will not be released until the account is paid in full.


2. A review of the staffing schedule as it pertains to registered nurse coverage for the medical/surgical unit revealed deficits in staffing as follows.

No Registered Nurse scheduled for the 12 hour shifts on the following dates and times:

March 4, 12 hour Day Shift March 4, 12 hour Night Shift

March 8, 12 hour Day Shift March 5, 12 hour Night Shift

March 10, 12 hour Day Shift

March 14, 12 hour Day Shift

March 16, 12 hour Day Shift

March 17, 12 hour Day Shift

March 18, 12 hour Day Shift

Interview conducted with the Human Resource Manager and the acting Director of Nursing on 3/21/12 at 4:00 PM revealed that the above referenced dates did not have Registered Nurse coverage.

3. Review of the preventive maintenance records for the Radiology Department on 03/202012 revealed that last time documented that the annual preventive maintenance was performed on the radiology equipment was 03/20/3010. No records of preventive maintenance records could be located for 2011 or 2012.

Interview with the lead technologist on 03/20/2012 at 2:00 PM revealed that she did not know if the preventive maintenance was performed as required.

Based on staff interviews and facility document review the facility failed to ensure a system approved by the governing body that authorizes physicians that can order outpatient procedures.

Findings:

Interview on 03/19/2011 at 4:00 PM of the Administrator revealed that the facility does not have a system approved by the governing body that provides for the authorization of which practitioners can order outpatient services.

Review of the facility bylaws did not reveal a system approved by the governing body that provides for the authorization of which practitioners can order outpatient services.