HospitalInspections.org

Based on staff interview, personnel record review, and review of governing body meeting minutes, the facility failed to ensure a contracted nurse employee working in the hospital adhered to the policies of the hospital.

Findings include:

The facility's Clinical Operations Organizational Chart effective 12/08/14 was reviewed on 09/09/15 at 2:00 PM. The name of the Interim Chief Nursing Officer was listed on the organizational chart.

The personnel record of the Chief Nursing Officer was reviewed on 09/09/15 at 4:00 PM. The record revealed the Chief Nursing Officer was an employee from August, 2014 until June 15, 2015. A signed contract revealed the Chief Nursing Officer was hired on 08/25/14.
The human resources checklist revealed the contracted CNO's registered nursing license expiration date was "pending" and was not yet verified. A copy from the Ohio Board of Nursing's license verification page dated 08/25/14 revealed the application for reciprocity was "pending." A second copy from the license verification page dated 10/13/14 revealed the status of the application for reciprocity was still pending. A third copy from the license verification page dated 10/20/14 revealed the status of the application for reciprocity was "application incomplete." A fourth copy from the license verification page dated 11/06/14 revealed the application remained incomplete.
Review of the Ohio Board of Nursing license verification page on 09/08/15 revealed the status of the application for reciprocity was still pending. The contract between the CNO and the facility was also reviewed. The following was noted as the 7th bullet point: "All is contingent upon consultant's passing a TB (tuberculosis) test, background check, physical, and securing Ohio Nursing license."
Staff A was interviewed on 09/10/15 at 10:30 AM and asked to provide documentation from the Governing Body meeting minutes that revealed the facility's governing body was made aware the Chief Nursing Officer did not hold a Ohio Nursing license. No documentation was provided. Documentation of an investigation to ensure that a future contractor was not permitted to work without an Ohio Nursing license was also requested. Again, no documentation was provided. Staff A was asked how the facility could ensure this did not happen again and he/she stated: "It's just not." It was confirmed with Staff A that a contracted registered nurse working in the facility must obtain an Ohio Nursing license prior to beginning work.