HospitalInspections.org

Based on interview and record review the facility failed to complete annual evaluations for two licensed staff (B and C) of four personnel records reviewed. The facility census was 90.

Findings included:

1. Record review of the personnel file for Staff B, Chief Nursing Officer, showed the most recent annual evaluation completed on 03/16/09. There is no evidence of a current annual evaluation:

Record review of the personnel record for Staff C, Director of Obstetrics, showed the most recent annual evaluation completed on 09/01/09. There is no evidence of a current annual evaluation:

2. During an interview on 05/12/11 at 10:05 AM, Staff V, Personnel Director, stated that the Chief Nursing Officer's annual evaluation was not current.

During an interview on 05/12/11 at 2:15 PM, Staff B, the Chief Nursing Officer, stated that he/she had the evaluation for the Director of Obstetrics on his/her desk to be completed. Staff B confirmed the annual evaluation for Staff C was not completed in 2010.

Based on observation, interview and staffing review the facility failed to provide an adequate number of licensed registered nurses in the outpatient wound center to ensure care is provided or supervised by a Registered Nurse (RN). The wound center cares for an average of 335 patients per month.

Findings included:

1. Observation on 05/11/11 at 2:30 PM, in the wound center showed Staff N as the only nurse on duty. Staff N is a Licensed Practical Nurse (LPN).

2. During an interview on 05/11/11 at 2:30 PM, Staff N, LPN, stated that he/she and the physician were the only staff on duty seeing patients and doing treatments of wounds in the wound center that day. Staff N stated that there is not always a registered nurse on duty in the wound center. Staff N stated that there is not always a registered nurse to oversee patient care and staff assignments.

During an interview on 05/12/11 at 1:00 PM, Staff B, Chief Nursing Officer, stated that the registered nurse in charge of the wound center is on medical leave.

During an interview on 05/12/11 at 1:20 PM, Staff O, Director of the Wound Center stated that the wound center cares for patients Monday through Friday. Staff O stated that currently the staffing is usually the physician, a licensed practical nurse and an assistant. Staff O stated that the registered nurse has been on medical leave since March, but there are some days when a registered nurse is assigned to the wound center.

3. Record review of the staffing document showed no registered nurse scheduled for the wound center for:
January 4 and 14, 2011
February 23 and 25, 2011
March 21,24,25,30 and 31, 2011
April 1,7,12,13,14,15,18,19,20, 21,22,25,27 and 29, 2011
May 2,3,4,6,9,10 and 11, 2011