HospitalInspections.org

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Based on interview and review of the personnel files of 8 hospital staff members, the hospital failed to ensure that all staff who provided direct patient care were licensed by the State of Washington, as demonstrated by 1 of 8 staff members reviewed (Staff #1).

Failure to ensure each health care provider has a current license puts patients at risk for receiving care from improperly trained and/or unqualified individuals.

Findings included:

1. On 07/09/19 at 2:50 PM, the investigator reviewed the personnel files of 8 hospital staff members currently employed to provide direct care to patients. This review showed that the license of a certified nursing assistant (Staff #1) had expired in April 2019.

2. During an interview with the investigator at the time of the file review, the hospital's Human Resource (HR) Coordinator (Staff #2) confirmed that the staff member's license had expired. The coordinator stated the HR department was currently working on a systematic process to track staff licenses. The process had not been developed and implemented at the time of the investigation.
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Based on interview and review of hospital policies and procedures, the Critical Access Hospital failed to notify long-term care ("swing bed") patients in writing of an impending transfer or discharge for 5 of 5 discharged patients reviewed (Patients #1, #2, #3, #4, #5).

Failure to notify swing bed patients of the reason for transfer or discharge, the effective date, the location to which the resident is being transferred or discharged, and information regarding the appeal process risks violation of the patient's rights as long-term care residents.

Findings included:

1. On 07/09/19 at 11:15 AM during an interview with the investigator, the Director of Nursing Services (Staff #3) stated that swing bed patients were not given written notice prior to discharge or transfer to another health care facility.

2. Review of the hospital's policy and procedures for its swing bed program showed that there was no procedure directing staff to notify patients in writing of the reason for their transfer or discharge, the effective date, the location to which the resident was being transferred or discharged, and information regarding the appeal process. There was no procedure directing staff to send a copy of the written notice to the Office of the State Long-Term Care Ombudsman when the patient was discharged against his or her will.
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