HospitalInspections.org

Based on interviews and document review, the hospital failed to ensure personnel were licensed or certified as required for 5 of 5 employees reviewed (Registered Nurse #2, #4, and #5 and Certified Nursing Assistant #1).

Findings:

The "Current Licensure/Certification and Registration" policy, last revised 9/2018, stated, "It is the policy of York Hospital to employ only those individuals who have proper licensure, certification or registration by the appropriate agency in those jobs requiring such status... License monitoring will be the responsibility of the Leaders... If appropriate documentation is not received by the day of expiration, the staff member will be unable to return to work in the same capacity until licensure has been renewed."

1. Certified Nursing Assistant (C.N.A.) #1's certification expired on 7/19/19. Documentation provided by the hospital's Human Resource Department indicated that this C.N.A. worked on 7/20/19 and 7/21/19.

A review of the C.N.A. and Direct Care Worker Registry website indicated that this C.N.A.'s certification was inactive on 7/20/19 through 7/24/19.

On September 3, 2019, at approximately 1:20 PM, the Director of Medical Surgical was interviewed. He verified C.N.A. #1 worked on 7/20/19 and 7/21/19.

2. RN #2's license expired on 5/5/19. Documentation provided by the hospital's Human Resource Department indicated that this RN worked on 5/6/19.

A review of the Maine State Board of Nursing's website indicated that this RN's license was inactive on 5/6/19 and 5/7/19.

On September 3, 2019, at approximately 2:30 PM, the Director of Quality was interviewed. He confirmed that the RN worked on 5/6/19 without an active license as reflected by documentation provided by Human Resources.

3. RN #4's license expired 7/6/19. Documentation provided by the hospital's Human Resource Department indicated that this RN worked on 7/7/19, 7/8/19, 7/11/19, and 7/19/19.

A review of the Maine State Board of Nursing's website indicated that this RN's license was inactive on 7/7/19 through 8/11/19.

On September 3, 2019, at approximately 2:30 PM, the Director of Quality was interviewed who confirmed that the RN worked on 7/7/19, 7/8/19, 7/11/19, and 7/19/19 without an active license as reflected by documentation provided by Human Resources.

4. RN #5's license expired 7/12/19. Documentation provided by the hospital's Human Resource Department indicated that this RN worked on 7/18/19, 7/19/19, and 7/20/19.

A review of the Maine State Board of Nursing's website indicated that this RN's license was inactive on 7/13/19 through 7/22/19.

On September 3, 2019, at approximately 2:30 PM, the Director of Quality was interviewed. He confirmed that the RN worked on 7/18/19, 7/19/19, and 7/20/19 without an active license as reflected by documentation provided by Human Resources.

On September 3, 2019 at approximately 3:00 PM, the hospital's Chief Executive Officer, Chief Nursing Officer, Chief Medical Officer, and Director of Quality were interviewed. This interview revealed that, as of 9/3/19, the hospital has not changed their system of monitoring certifications and licensure to ensure only personnel who have an active certification or license provide services to patients.