HospitalInspections.org

Based on Electronic Code of Federal Regulations (e-CFR) review, medical record reviews, observations and staff interviews, the hospital's leadership failed to ensure the Critical Access Hospital (CAH) provided written notice to all inpatients at the beginning of an inpatient stay, and to outpatients for certain types of outpatient visits, that there were no doctors of medicine or osteopathy present in the hospital 24 hours per day, 7 days per week for 2 of 2 open Medical-Surgical unit patient medical records reviewed (Patients #9 and #7); and failed to conspicuously post a notice in a place or places likely to be noticed by all individuals entering the dedicated emergency department (DED) stating that the hospital did not have a Doctor of Medicine (MD) or Osteopathy (DO) present in the hospital 24 hours per day, 7 days per week for 1 of 1 emergency departments toured (DED #1).

Findings included:

Review on 04/13/2017 of the U.S. Government Publishing Office (GPO), Electronic Code of Federal Regulations (e-CFR) retrieved from https://www.ecfr.gov/cgi-bin/text-idx?SID=0679737735875f6f1264adf02c688706&mc=true&node=se42.5.489_120&rgn=div8; e-CFR data current as of April 19, 2017, revealed Title 42 (Public Health), Chapter IV, Subchapter G, Part 489 (Provider Agreements and Supplier Approval), Subpart B (Essentials of Provider Agreements), §489.20 "Basic commitments. The provider agrees to the following: ...(w)(1) In the case of a hospital as defined in §489.24(b), to furnish written notice to all patients at the beginning of their planned or unplanned inpatient hospital stay or at the beginning of any planned or unplanned outpatient visit for observation, surgery or any other procedure requiring anesthesia, if a doctor of medicine or a doctor of osteopathy is not present in the hospital 24 hours per day, 7 days per week, in order to assist the patients in making informed decisions regarding their care, in accordance with §482.13(b)(2) of this subchapter. For purposes of this paragraph, a planned hospital stay or outpatient visit begins with the provision of a package of information regarding scheduled preadmission testing and registration for a planned hospital admission for inpatient care or outpatient service. An unplanned hospital stay or outpatient visit begins at the earliest point at which the patient presents to the hospital. (2) In the case of a hospital that is a main provider and has one or more remote locations of a hospital or one or more satellites, as these terms are defined in §413.65(a)(2), §412.22(h), or §412.25(e) of this chapter, as applicable, the determination is made separately for the main provider and each remote location or satellite whether notice to patients is required. Notice is required at each location at which inpatient services are furnished at which a doctor of medicine or doctor of osteopathy is not present 24 hours per day, 7 days per week. (3) The written notice must state that the hospital does not have a doctor of medicine or a doctor of osteopathy present in the hospital 24 hours per day, 7 days per week, and must indicate how the hospital will meet the medical needs of any patient who develops an emergency medical condition, as defined in §489.24(b), at a time when there is no doctor of medicine or doctor of osteopathy present in the hospital. (4) Before admitting a patient or providing an outpatient service to outpatients for whom a notice is required, the hospital must receive a signed acknowledgment from the patient stating that the patient understands that a doctor of medicine or doctor of osteopathy may not be present during all hours services are furnished to the patient. (5) Each dedicated emergency department, as that term is defined in §489.24(b), in a hospital in which a doctor of medicine or doctor of osteopathy is not present 24 hours per day, 7 days per week must post a notice conspicuously in a place or places likely to be noticed by all individuals entering the dedicated emergency department. The posted notice must state that the hospital does not have a doctor of medicine or a doctor of osteopathy present in the hospital 24 hours per day, 7 days per week, and must indicate how the hospital will meet the medical needs of any patient with an emergency medical condition, as defined in §489.24(b), at a time when there is no doctor of medicine or doctor of osteopathy present in the hospital. ..."

1. Open medical record review on 04/12/2017 for Patient #9 revealed a 89-year-old male patient admitted in-patient to the Medical-Surgical unit, room 123 on 04/11/2017 with a diagnosis of left lower lobe pneumonia and altered mental status. Medical record review failed to reveal any available documentation that a written notice was provided to the patient informing him that there were no doctors of medicine or osteopathy present in the hospital 24 hours per day, 7 days per week.

Interview on 04/12/2017 at 1329 with MD #1, revealed he was the hospital's chief of staff and emergency department's medical director. Interview revealed the hospital did not have a physician (MD or DO) physically present in the hospital 24 hours a day, 7 days per week. They are available by cell phone. Interview confirmed the findings.

Interview on 04/13/2017 at 0950 with the hospital's Chief Nursing Officer, revealed the hospital did not have a doctor of medicine or osteopathy present in the hospital 24 hours per day, 7 days per week and patients were not provided a written notice of such at the beginning of an inpatient stay or applicable outpatient visit. Interview confirmed the medical record review findings.

2. Open medical record review on 04/12/2017 for Patient #7 revealed a 22-year-old female patient admitted observation to the Medical-Surgical unit, room 148 on 04/10/2017 with a diagnosis of Nephrolithiasis, non-obstructing and Intractable pain, nausea, and vomiting. Medical record review failed to reveal any available documentation that a written notice was provided to the patient informing her that there were no doctors of medicine or osteopathy present in the hospital 24 hours per day, 7 days per week.

Interview on 04/12/2017 at 1329 with MD #1, revealed he was the hospital's chief of staff and emergency department's medical director. Interview revealed the hospital did not have a physician (MD or DO) physically present in the hospital 24 hours a day, 7 days per week. They are available by cell phone. Interview confirmed the findings.

Interview on 04/13/2017 at 0950 with the hospital's Chief Nursing Officer, revealed the hospital did not have a doctor of medicine or osteopathy present in the hospital 24 hours per day, 7 days per week and patients were not provided a written notice of such at the beginning of an inpatient stay or applicable outpatient visit. Interview confirmed the medical record review findings.



26622

3. Observations during tour of the Dedicated Emergency Department (DED #1) on 04/13/2017 at 1430 revealed no notice/signage conspicuously posted in a place or places likely to be noticed by all individuals entering the dedicated emergency department stating that the facility did not have a doctor of medicine or osteopathy present in the hospital 24 hours per day, 7 days per week and how the facility will meet the medical needs of any patient with an emergency medical condition.

Interview on 04/13/2017 at 0950 with the hospital's Chief Nursing Officer, revealed the hospital did not have a doctor of medicine or osteopathy present in the hospital 24 hours per day, 7 days per week. There were no notices/signage posted conspicuously in a place or places likely to be noticed by all individuals entering the emergency department stating the hospital did not have a doctor of medicine or osteopathy present in the hospital 24 hours per day, 7 days per week and how the facility will meet the medical needs of any patient with an emergency medical condition. Interview confirmed the findings.

Interview on 04/13/2017 at 1445 with Registered Nurse (RN) #2 revealed he was not aware of any notices and did not know the patients presenting to the dedicated emergency department had to be made aware that there was no doctor present in the hospital 24 hours per day, 7 days a week. Interview confirmed the findings.

Interview on 04/13/2017 at 1450 with RN #5 revealed he was not aware of any notices and did not know the patients presenting to the dedicated emergency department had to be made aware that there was no doctor present in the hospital 24 hours per day, 7 days a week. Interview confirmed the findings.

Based on current hospital policy review, Medical Staff Bylaws' Rules and Regulations review, Emergency Department Provider schedule reviews, Physician On-Call schedule reviews, Diversion log reviews, Physician and Staff interviews, the hospital's leadership failed to ensure a practitioner with training and experience in emergency care was on-call and immediately available to provide emergency services to patients who presented to the emergency department 24 hours a day, 7 days a week as evidenced by the hospital's nursing staff failing to follow established diversion policy and procedures for 1 of 1 emergency departments (ED #1).

Findings included:

Review on 04/11/2017 of current policy "EMTALA Diversion Policy", policy/procedure #: 6231.803, revised 08/02/2016, revealed "...POLICY ....County Hospital will divert in-bound ambulances to other facilities when they lack the capacity and capability to properly care for the patient at the hospital. If a person arrives at the hospital despite the diversion, ....County Hospital will provide appropriate emergency screening with treatment and/or initiate a proper transfer to another facility....PROCEDURE ...c. Persons Who Arrive at....County hospital Despite Diversion Status. If a person arrives at the hospital seeking emergency care, the hospital will provide an appropriate medical screening examination, stabilizing treatment and/or an appropriate transfer consistent with EMTALA. The hospital will provide such care whether or not the entity is on Diversion Status, and whether or not the person or ambulance disregarded the hospital's attempt to divert the person. ...2. DIVERSION STATUS. ...a. Standard for Diversion. The hospital may initiate Diversion Status if hospital lacks the capacity or capability to care for additonal emergency patients after considering: *The overall best interests of patients and persons who need emergency services. *The number and availability of qualified staff, beds and equipment reasonably necessary to care for additional emergency patients. In determining available resources, the hospital should include resources that would otherwise be reserved for potential inpatient emergencies or anticipated elective admission. ...b. Efforts to Avoid Diversion. The hospital will initiate Diversion Status only after the hospital has exhausted all internal resources to meet the current patient load, including reasonable attempts to call back staff; expedite appropriate discharges; open additional available be beds appropriate for emergency patient care; etc. ..."

Review on 04/11/2017 of current Medical Staff Bylaws, Rules and Regulations, adopted 01/17/2013, revealed "...II. Emergency Department Services. ...L. All members of the Active Medical staff shall be required to be available for coverage of the Hospital's Emergency Department. Specific duties shall be established....to sustain and insure [sic] the adequacy of physician coverage for the Department. ..."

Review on 04/12/2017 of "...MDOnCallSchedule [n.d.]" for 03/19/2017 to 04/13/2017, revealed one (1) physician scheduled per day to be on-call from 0700 to 0700 for the hospital and emergency department. Review revealed MD #1 was scheduled to be on-call for the ED on 04/04/2017 from 0700 to 0700.

Review on 04/12/2017 of "...ProviderSchedule3_19_17ver (version) 8 [n.d.] " for 04/02/2017 to 04/15/2017, revealed ED Providers were scheduled to worked 24 hour shifts from 0700 to 0700. On 04/03/2017, Nurse Practitioner (NP) #1 was scheduled to work a 24 hour shift. On 04/04/2017 MD #2 was scheduled to work a 24 hour shift. Review of "...ProviderSchedule3_19_17ver10 [n.d.]" for 04/02/2017 to 04/15/2017, revealed ED Providers were scheduled to worked 24 hour shifts from 0700 to 0700. On 04/03/2017, NP #1 was scheduled to work a 24 hour shift. On 04/04/2017, MD #2 had been removed from working the 24 hour shift and the shift was marked as "24 UNCOVERED." Review of "...ProviderSchedule3_19_17ver16 [n.d.]" for 04/02/2017 to 04/15/2017, revealed ED Providers were scheduled to worked 24 hour shifts from 0700 to 0700. On 04/03/2017, Nurse Practitioner (NP) #1 was scheduled to work a 24 hour shift. On 04/04/2017 NP #1 was scheduled to work a 24 hour shift (for 48 consecutive hours). Review of "...ProviderSchedule3_19_17ver17 [n.d.]" for 04/02/2017 to 04/15/2017, revealed ED Providers were scheduled to worked 24 hour shifts from 0700 to 0700. On 04/03/2017, Nurse Practitioner (NP) #1 was scheduled to work a 24 hour shift. On 04/04/2017 NP #1 was scheduled to work from 1500 to 0700. Review revealed no ED Provider scheduled to work on 04/04/2017 from 0700 to 1500 (8 hours).

Review on 04/11/2017 of "(Hospital A) ED DIVERT CHECKLIST" dated 04/04/2017 at 0820 revealed the hospital's emergency department went on "Diversion" from 0820 until 1430 (6 hours 10 minutes). The hospital's Chief Executive Officer, ED Provider (NP #1), Medical Chief of Staff (MD #1), ED Charge Nurse, Nursing Supervisor/Chief Nursing Officer, Radiology Supervisor, and Lab Supervisor were notified of the diversion. Additionally, the local county EMS Agency and four (4) surrounding area hospitals were notified of Hospital A's ED diversion status. Review revealed, "Divert Type, Total ER Divert, Hospital Admission" and "Check Criteria" with "[check mark in box] Other: Staffing issues." Review of nursing documentation by RN #2 at 0820, revealed "Staffing issues beginning at 0900; at 0900 "Code Yellow in effect"; and at 1430 "Code yellow/diversion terminated."

Interview on 04/12/2017 at 1055 with NP #1 revealed she was scheduled to work a 24 hour shift on 04/03/2017. Interview revealed she had no provider relief at 0700 (end of her shift) on 04/04/2017. Interview revealed she left the Emergency Department around 9:45 a.m. to get a few hours of rest/sleep after all patients had been seen and discharged. Interview revealed there was no discussion with administration of contacting her to see patients during her rest/sleep time. Interview revealed she was on-site in the on-call room sleeping. Interview revealed she returned to the Emergency Department to staff between 1430 and 1500 on 04/04/2017.

Interview on 04/12/2017 at 1445 with Registered Nurse (RN) #2 revealed he was working on 04/04/2017 from 0600 - 1800. Interview revealed NP #1 worked a 24 hour shift on 04/03/2017 and was scheduled to get off at 0700. Interview revealed patients presented to the Emergency Department the morning of 04/04/2017 and "I asked if she was taking patients or was the new provider. I looked in the provider book and saw no one was scheduled." Interview revealed the schedule indicated an X mark with uncovered on the provider schedule for 04/04/2017. Interview revealed RN #2 discussed the situation with his supervisor and asked who was covering. Interview revealed NP #1 agreed to work until 0900 at which time if no one had been found to cover, the Emergency Department would go on diversion. Interview revealed the Emergency Department was placed on "Complete Diversion". Interview revealed complete diversion was explained to him as meaning "they could not accept any patients into the Emergency Department". Interview revealed the Chief Nursing Officer had told them if someone presented that was very sick, they could call the Medical Director (MD #1) who was located across the driveway from the Emergency Department. Interview revealed the supervisor was told by Emergency Department nurses that they could not selectively pick who needs to be seen if they were closed. Interview revealed they had one patient (a child with a bug in the ear) with their mother present during the diversion and the patient and mother were directed across the driveway to the Medical Director's office to be seen as a walk-in. Interview revealed they were told if an emergent patient arrived to call Emergency Medical Services (ambulance) to take patient to another hospital.

Interview on 04/12/2017 at 1500 with Registration Clerk (RC) #3 and RC #4 revealed one patient presented to the registration desk during the diversion on 04/04/2017 and they were directed to speak with the nurse in the Emergency Department.

Interview on 04/12/2017 at 1510 with RN #5, revealed she was working 0600 - 1800 on 04/04/2017. Interview revealed "I didn't see a provider on the schedule for that day". Interview revealed the provider (NP #1) from 04/03/2017 was asked to stay until 0900. Interview revealed administration was unable to find provider coverage for 04/04/2017 and told them they would go on "complete diversion". Interview revealed "I called all the area hospitals to let them know we were on complete diversion and we are not accepting patients at this time until further notice as we are not able to see any patients at this time." Interview revealed she did recall hearing two calls go out for Emergency Medical Service (ambulance). Interview revealed they did have one walk-in patient present during the diversion and the mother was instructed to take the child across the driveway to the Medical Director's office.

Interview on 04/12/2017 at 1329 with MD #1, revealed he was the hospital's chief of staff and emergency department's medical director. He was an employee of the hospital. Generally, he did not staff the ED as a provider. The ED providers were once contracted employees of "RAMP (a contracted medical provider group)." In March (2017), the hospital changed over to hospital employed providers covering the ED. The ED was currently staffed using midlevel providers (Nurse Practitioners [NP] and Physician Assistants' [PA]). The ED providers cover both the ED and inpatient Medical-Surgical floor. The hospital did not have a physician (MD or DO) physically present in the hospital 24 hours a day. The hospital had three (3) physicians (including himself) that provided physician on-call coverage for the ED 24 hours a day. He and MD #2 had been alternating on-call weeks and every other weekend since October (2016). When on-call they were available via cell phone. As the ED Medical Director he was made aware of when the hospital's ED was placed on diversion status. The decision to go on diversion status was made by the on-duty ED provider and hospital administration. He recalled the hospital ED had been on diversion status several times since January 2017. The last time the hospital ED went on total diversion was in April (04/04/2017). He was made aware on 04/04/2017 that the hospital's ED was placed on total diversion status. He was made aware of the diversion status by the hospital's CEO. The CEO came over to his clinic (located on campus) and spoke with him about a provider (NP #1) being on-duty for 24 hours (on 04/03/2017) and the on-coming provider (for 04/04/2017) getting sick or having a family emergency and was not able to staff the ED. MD #1 stated he was the physician scheduled to be on-call for the ED on 04/04/2017. He advised the ED staff could call him if someone needed to be seen. He was available in his clinic. "All staff had to do was call." Interview revealed his clinic was owned by the hospital and was located on the hospital's campus. Further interview revealed, "When push comes to shove they (hospital administration) could have requested me to reschedule my patients and come work in the ED. I am an employee of the hospital." MD #1 revealed he was on-call and immediately available to provide emergency services to patients who presented to the emergency department on 04/04/2017. Interview confirmed the findings.

Interview on 04/13/2017 at 0950 with the Chief Nursing Officer (CNO) revealed the hospital's ED had been on diversion status 3-4 times since February 2017. The hospital goes on diversion status when critical items or staffing are unavailable. The hospital has an established diversion policy. When the hospital's ED goes on diversion, hospital leadership, local EMS and surrounding hospitals are notified. It was not the CEO or CNO's role to determine when the hospital's ED went on or off diversion. The ED Medical Director (MD #1), approves the ED going on diversion status and also makes the decision to take the ED off diversion status. She was aware the hospital's ED went on diversion status on 04/04/2017 for a "provider staffing issue." The hospital transitioned over to hospital employed providers (NP, PA) staffing the ED. The ED providers worked 24 hour shifts. The hospital also used locum tenens to cover ED shifts. The contract with the former contracted ED provider group ended 03/27/2017 and the hospital employed providers started 03/28/2017. Initially, MD #2 was scheduled to work a 24 hour shift on 04/04/2017, but was removed and the 24 hour shift was "left uncovered." NP #1 was already scheduled to work a 24 hour shift on 04/03/2017 and was then scheduled to work the 24 hour shift on 04/04/2017 (total 48 hour shift). She (CNO) did not allow NP#1 to work the 48 hour shift. "(NP #1) needed at least 8 hours of sleep." NP #1 stayed in-house and slept in the call room located on the Medical-Surgical floor. NP #1 was scheduled to work 1500 to 0700 (04/04/2017) after getting 8 hours sleep. If a patient presented to the hospital's ED while on diversion status while NP #1 was sleeping, the ED nursing staff should have called MD #1 to come see the patient. MD #1 was the physician on-call. MD #1 would have come to the ED. "As a last resort they (ED nursing staff) could have woke her (NP#1) up." Interview revealed she was unaware that any patients had been turned away from the ED on 04/04/2017 while NP #1 was sleeping as reported during staff interviews with RN #2, RN #5, RC #3 and RC #4 on 04/12/2017. If a patient presented on the hospital's campus for medical evaluation, they should have been seen in the ED and had a medical screening examination and if needed, transferred to another hospital. Interview revealed she could not find any evidence where ED staff had been educated and trained on the hospital's diversion policy. The CNO stated she contacted MD #1's clinic and the clinic staff reported they had no record of any patients presenting to the clinic from the ED on 04/04/2017. Interview confirmed the findings.

In summation, the hospital's leadership and nursing staff in efforts to avoid diversion status, failed to initiate diversion only after the hospital had exhausted all internal resources to meet patient needs per policy; by failing to notify the available on-call physician (MD #1) or notify NP #1 who was on-site and available in the on-call room, that a patient presented to the ED during the timeframe when the ED was left unattended by a qualified provider from 0900 to 1430 on 04/04/2017.

Based on review of hospital clinical services policies and staff interview, the hospital's staff failed to ensure patient care policies were reviewed at least annually for 31 of 31 policies reviewed during survey.

Findings included:

Review on 04/13/2017 of hospital clinical services policies, revealed fifteen (15) policies last reviewed in October, 2012 (4 years and 6 months past due), one (1) policy last reviewed in February, 2013 (4 years and 2 months past due), eight (8) policies last reviewed in November, 2013 (3 years and 5 months past due), one (1) policy last reviewed in November, 2014 (2 years and 5 months past due) and six (6) policies last reviewed in February, 2016 (2 months past due).

Interview with Chief Nursing Officer on 04/13/2017 at 1425 revealed she along with nursing management staff and medical staff were responsible for reviewing the policies and making revisions as needed. Interview revealed the policies should be reviewed/revised annually. Interview revealed the clinical services policies were "out of compliance" with the hospital policy. Interview confirmed the findings.

Based on review of hospital policy and procedure, review of medical records, review of personnel files and staff interviews, the nursing staff failed to obtain a provider order for a Foley catheter for 1 of 1 sampled patients with a Foley catheter (Patient #6); and failed to ensure the evaluation of on-going competencies and annual performance evaluations of the nursing staff were completed for 7 of 8 nursing staff files reviewed (Files #2, #7, #3, #6, #8, #4 and #1).

Findings included:

A. Review on 04/12/2017 of hospital policy and procedure index revealed no available documentation of a policy in the index to address Foley catheter procedures.

Review of medical record on 04/12/2017 for Patient #6 revealed a 59 year old male presented to the Emergency Department on 02/19/2017 at 0235 with a chief complaint of shortness of breath. Review of the provider's written orders at 0235 revealed orders for lab tests, chest x-ray, 12 lead electrocardiogram (tracing of heart), Cardiac and Blood Pressure monitors, oxygen at 6 Liters/minute with continuous pulse oximetry monitoring and intravenous saline lock (no fluids). Review of nursing notes revealed a Foley catheter was inserted by the Nursing Assistant at 0300 for urine collection. Further review of nursing notes revealed bright red blood returned in Foley and provider was notified. Review of provider's note at 0300 revealed provider was notified by nursing of frank blood in the Foley catheter after insertion and provider gave a verbal order to remove the Foley catheter. Review of medical record revealed no documentation of a provider's written order to insert a Foley catheter and no provider's verbal order documented to remove the Foley catheter. Review of the provider notes documented at 0520 revealed urology telephone consult was made and recommendation to re-insert the Foley catheter. Further review of provider notes revealed the nurse was unable to re-insert the Foley and bleeding continued. Further review of provider notes revealed the patient was accepted by a urologist at the other facility. Review of medical record revealed Patient #6 was transferred by ground ambulance to the other facility at 0700.

Interview on 04/12/2017 at 1145 with Certified Nursing Assistant (CNA) #2, revealed the nurse asked her to insert a Foley catheter in Patient #6. Interview revealed she was the nursing assistant that placed the Foley catheter the first time and saw initially urine and then a small amount of blood. Interview revealed she immediately reported information to the registered nurse and the nurse practitioner ordered the Foley catheter to be removed. Interview revealed the nurse practitioner then told the nurse to re-insert the Foley. Interview revealed the nurse attempted to re-insert the Foley catheter but met resistance and notified the provider.

Interview on 04/12/2017 at 2200 with Registered Nurse (RN) #6, revealed she was the primary nurse who cared for Patient #6 on 02/19/2017. Interview revealed the provider wrote an order for a urinalysis and Lasix (diuretic medication). Interview the "In the ED (Emergency Department) 9 out of 10 times if a patient is non-ambulatory, getting Lasix and need to track I/O (intake and output), it's a given to insert a Foley catheter". Further interview revealed there was no order for a Foley catheter ordered by the provider. Interview confirmed the findings.

Interview on 04/13/2017 at 1425 with Chief Nursing Officer revealed there were no hospital policies that addressed Foley catheter insertions. Interview revealed there was no provider order for insertion of Foley catheter for Patient #6. Interview revealed there were no standing orders/nursing protocols for Foley catheter procedure available for review. Interview confirmed the findings.



38584

B. Review on 04/13/2017 of hospital policy and procedure, "Competency Assessment ...Clinical Services ...Revision Date 2/13/13", revealed "1 ...d. Ongoing (annual) competency assessment last [sic] throughout the individual's tenure with the hospital via annual performance appraisal, required hospital competency and department specific competency assessment ...2 ...a. All Nursing staff shall participate in a Competency Assessment program ...iv. Annually the employee will participate in the following: a) Performance appraisal, b) Review of job description, c) Required hospital competency, d) Required Nursing Department competency ...d. Annual Competencies for Certified Nurse Assistants..."

1. Review on 04/12/2017 of personnel file #2 revealed the RN was hired on 04/12/2015. File review revealed no available documentation of an annual performance evaluation or annual competencies since hire (greater than 1 year).

Interview on 04/12/2017 at 1622 with the Chief Nursing Officer revealed the competencies and evaluations were to be completed annually per the hospital policy and they had not been done.

Interview on 04/13/2017 at 1325 with the Human Resource Manager revealed there was no additional information for the personnel files. Interview revealed the supervisory staff failed to follow hospital policy to conduct annual staff competencies and performance evaluations.

2. Review on 04/12/2017 of the personnel file #7 revealed the CNA/Unit Secretary was hired on 02/08/2002 and the most recent employee performance evaluation was signed by the employee on 02/18/2016 (greater than 1 year). Review revealed no available documentation of annual competencies since hire (greater than 1 year).

Interview on 04/12/2017 at 1622 with the Chief Nursing Officer revealed the competencies and evaluations were to be completed annually per the hospital policy and they had not been done.

Interview on 04/13/2017 at 1325 with the Human Resource Manager revealed there was no additional information for the personnel files. Interview revealed the supervisory staff failed to follow hospital policy to conduct annual staff competencies and performance evaluations.

3. Review on 04/12/2017 of personnel file #3 revealed the CNA II was hired on 05/29/2012 and the most recent performance evaluation signed by the employee was on 07/02/2015 (greater that 1 year ago), and the most recent annual competencies were signed on 09/05/2015 (greater than 1 year ago).

Interview on 04/12/2017 at 1622 with the Chief Nursing Officer revealed the competencies and evaluations were to be completed annually per the hospital policy and they had not been done.

Interview on 04/13/2017 at 1325 with the Human Resource Manager revealed there was no additional information for the personnel files. Interview revealed the supervisory staff failed to follow hospital policy to conduct annual staff competencies and performance evaluations.

4. Review of personnel file #6 revealed the RN was hired on 08/07/2006 and the most recent performance evaluation signed by the employee was on 11/17/2015 (greater than 1 year), and the most recent annual competencies were signed on 11/19/2013 (greater than 1 year).

Interview on 04/12/2017 at 1622 with the Chief Nursing Officer revealed the competencies and evaluations were to be completed annually per the hospital policy and they had not been done.

Interview on 04/13/2017 at 1325 with the Human Resource Manager revealed there was no additional information for the personnel files. Interview revealed the supervisory staff failed to follow hospital policy to conduct annual staff competencies and performance evaluations.



34157

5. Review on 04/12/2017 of personnel file #8 revealed the CNA I was hired on 12/01/2012 and the most recent performance evaluation signed by the employee was on 07/01/2013 (greater than 1 year), and the most recent annual competencies were signed on 11/19/2013 (greater than 1 year).

Interview on 04/12/2017 at 1622 with the Chief Nursing Officer revealed the competencies and evaluations were to be completed annually per the hospital policy and they had not been done.

Interview on 04/13/2017 at 1325 with the Human Resource Manager revealed there was no additional information for the personnel files. Interview revealed the supervisory staff failed to follow hospital policy to conduct annual staff competencies and performance evaluations.

6. Review on 04/12/2017 of personnel file #4 revealed the CNA/Monitor Technician was hired on 08/17/2011 and the most recent employee performance evaluation was signed by the employee on 02/04/2015 (greater than 1 year). The most recent annual competences were signed by the evaluator on 11/19/2013 (greater than 1 year). The file included a certification for Basic ECG (electrocardiogram) class of 4 hours dated 01/30/2013 (greater than 1 year).

Interview on 04/12/2017 at 1622 with the Chief Nursing Officer revealed the competencies and evaluations were to be completed annually per the hospital policy and they had not been done.

Interview on 04/13/2017 at 1325 with the Human Resource Manager revealed there was no additional information for the personnel files. Interview revealed the supervisory staff failed to follow hospital policy to conduct annual staff competencies and performance evaluations.

7. Review on 04/12/2017 of personnel file #1 revealed the LPN (licensed practical nurse) was hired on 05/11/2015 and the most recent annual competencies were signed on 09/13/2015 (greater than 1 year ago). Review revealed a current performance evaluation.

Interview on 04/12/2017 at 1622 with the Chief Nursing Officer revealed the competencies and evaluations were to be completed annually per the hospital policy and they had not been done.

Interview on 04/13/2017 at 1325 with the Human Resource Manager revealed there was no additional information for the personnel files. Interview revealed the supervisory staff failed to follow hospital policy to conduct annual staff competencies and performance evaluations.

NC00126691
NC00126715