HospitalInspections.org

Based on review of personnel files and staff interview, it was determined that the Hospital failed to ensure personnel files were up to date with current job descriptions, orientation checklists and competencies.

Findings include:

A review of eight (8) personnel files revealed six (6) employee files were from the former management company. Four employee files had job descriptions from the former management company. Six (6) employees had orientation checklists and competencies from the former management company. Two (2) employees had no orientation checklists or competencies present in the personnel file. Two (2) employees did not have documentation of a Basic Life Support (BLS) certifications in the personnel file. One (1) employee did not documentation an Advanced Cardiac Life Support (ACLS) certification present in the personnel file. One (1) employee did not have documentation of Crisis Prevention Institute (CPI) training in the personnel file. Two (2) employees files did not reveal evidence of a current tuberculosis test or screening.

Employee #3 confirmed during an interview on 03/24/2022 that the hospital was using the former management company's personnel files for the hospital's current employees. Employee #3 confirmed the personnel files were incomplete and did not contain all the required documentation.

Based on Center for Disease Control and Prevention (CDC) guidelines, observation and staff interviews, it was determined that the Hospital failed to ensure staff wore facemasks in patient care areas which poses a risk to the health and safety of patients by potentially exposing patients, visitors and staff to infections.

Findings include:

CDC guidelines titled "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, 02/02/2022" revealed: "...Implement Dource Control Measures: Source control refers to the use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing...Source control and physical distancing (when physical distancing is feasible and will not interfere with the provision of care) are recommended for everyone in a healthcare setting. This is particularly important for individuals, regardless of their vaccination status, who live or work in counties with substantial to high community transmission or who have:...Healthcare Professionals (HCP) who are up to date with all recommended COVID-19 vaccine doses: could choose not to wear source control or physically distance when they are in well-defined areas that are restricted from patient access (e.g., staff meeting rooms, kitchen). They should wear source control when they are in areas of the healthcare facility where they could encounter patients (e.g. hospital cafeteria, common hall/corridors)...."

Observation on 03/24/2022 revealed upon entrance to the hospital all staff and patients observed were not wearing facemasks.

Employee #2 confirmed in an interview on 03/24/2022 that masks were no longer required to be worn per instructions from the Director of Nursing.

Based on review of credentialing files, medical staff bylaws, job description, and interview, it was determined that the facility failed to ensure Provider #16's credential file contained evidence of current licensure in the State of Arizona which poses a risk to the health and safety of patient's if a provider is not licensed to provide medical and/or psychiatric services.

Findings include:

Review of credentialing files revealed the following:

Provider #16 is currently employed at the facility as a per diem psychiatric nurse practitioner. Provider #16's credential file did not contain evidence of a current Arizona ARNP license.

The facility document "Bylaws of the Medical Staff of Talas Harbor at Bullhead City" requires: "...Physician Qualifications for Medical Staff Membership and Clinical Privileges...Threshold Eligibility Qualifications...Current unrestricted license to practice relevant profession in the State...."

The job description titled "Nurse Practitioner" requires: "...Current Arizona ARNP License...."

Employee #3 confirmed on 03/24/2022, that Provider #16's credential file did not contain evidence of a current Arizona ARNP license. Employee #1 and 2 confirmed on 03/24/2022, that Provider #16 is a per diem psychiatric services provider at the hospital

Based on review of personnel file and staff interview, it was determined the Hospital failed to ensure the Director of Nursing's (DON)personnel file reflected qualifications for the position.

Findings include:

Review of the DON's personnel file revealed the following: a job description and a copy of registered nursing license. Further review revealed no evidence of Basic Life Support and Advance Cardiac Life Support certifications. Review of the personnel file revealed no Crisis Prevention Institute certification or Abuse training. Further review revealed no evidence of an orientation checklist, competency training or tuberculosis testing or screening.

Employee #3 confirmed during an interview on 03/24/2022 that the personnel file for the Director of Nursing was incomplete.

Based on review of policies and procedures, staffing assignments and schedules, and staff interviews, it was determined that the Hospital failed to ensure there was at least one (1) registered nurse (RN) and one (1) other nurse on the hospital premises. The deficient practice poses a risk to the health and safety of patients during an emergency or other crisis situation if there is not sufficient staffing.

Findings include:

A request was made for the hospital's staffing and acuity plan. No policy or plan was provided. A document titled "Talas Harbor BHC Behavioral Hospital Acuity Tool Screening Definitions" was provided.

A review of the hospital staffing assignment sheets from 03/01/2022 through 03/23/2022 were reviewed. Of the forty-six (46) shifts within the review timeframe, fourteen (14) shifts had only one (1) RN and one (1) tech assigned to work the unit.

Observation on 03/24/2022 revealed one (1) RN with two (2) techs working the unit.

Employee #8 confirmed during an interview on 03/24/2022 that s/he was the only RN in the hospital and the staffing assignment for the day was one (1) RN and two (2) techs.

Employee #3 confirmed during an interview on 03/24/2022 that there have been numerous shifts were only one (1) RN was on the premises. Employee #3 stated the hospital had an agreement with the skilled nursing facility next door to utilize one of that facility's nurse for back up and relief if necessary.