HospitalInspections.org

Based on review of employee files, PRN Medical Staffing agreement and interview, the facility failed to assure nursing licenses were current and valid for 7 (#1-2, #4-5, #7, #9-10) of 10 (#1-10) nursing staff. The failed practice did not assure Registered Nurses (RN) were qualified to deliver patient care requiring licensure (i.e. narcotic administration, patient assessments) or that Licensed Practical Nurses (LPN) were qualified to deliver patient care requiring licensure (i.e. medication administration, observing for signs and symptoms of complications) and had the potential to affect all patients admitted to the facility. Findings follow:

A. Review of employee files for Nursing Staff #1, #2, #4, #5, #7, #9, #10 revealed they did not have evidence of license verification.
B. Review of PRN Medical Staffing agreement revealed the Agency's goals were to provide the most qualified employees but did not have evidence of what the employee's qualifications were or if licenses were verified.
C. On interview 05/15/12 at 1515 with the Vice President of Human Resources confirmed she did not verify licenses for the facility's nursing staff or for the PRN (as needed) nursing staff.
D. Findings were verified with the Case Manager on 05/15/12 at 1530.

Based on review of clinical records, policy and procedure manual and interview the facility failed to assure care plans were developed for 7 (#2-6, #8-9) of 10 (#1-10) patients admitted to the facility. The failed practice did not assure goals were established for patients according to individual needs or the goals were evaluated, addressed, revised and/or updated and had the potential to affect all patients admitted to the facility. Findings follow:

A. Review of the clinical records for Patients #2-6 and #8-9 revealed they did not have evidence of a care plan.
B. Review of Policy, "Care Plan" revealed "a nursing care plan will be completed on every acute or monitored care patient admitted to the Med/Surg (Medical Surgical) unit as an inpatient. It is the responsibility of the Registered Nurse admitting the patient to start the care plan. It will be revised as needed and reviewed once every 24 hours by a licensed nurse."
C. On interview with the Case Manager on 05/15/12 at 1415 she verified there were no care plans in the clinical records for Patients #2-6 and #8-9 and stated that all patients were to have care plans generated upon admission.
D. Findings were verified with the Case Manager on 05/15/12 at 1430.