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Based on observation, interview and record review, the facility failed to evaluate 2 of 2 agency staff for competency after the first shift worked found working on the nursing units.
Findings included:
Review of the facility policy-Placement of Agency Staff, Students or Other Contract Labor, dated as effective 10/15/2010, states " The supervisor is responsible for evaluating all contract labor for competency during their first shift. " During tour and observation of the second floor intensive care nursing unit on 09/14/2011 at 1:50 p.m. agency registered nurse (RN), staff Q was observed to work and care for patients. During tour and observation of the second floor progressive care nursing unit on 09/14/2011 at 2:20 p.m., agency registered nurse (RN), staff T was observed to work and care for patients.

Review of the personnel file for staff Q showed she worked 09/07/2011 and 09/14/2011. The personnel file did not show an evaluation after the first shift worked. Review of the personnel file for staff T showed she worked a total of nine days in the past thirty days, including 09/14/2011. The personnel file did not show an evaluation after the first shift worked.
During an interview on 09/15/2011 at 11:15 a.m., the CEO confirmed the agency staff personnel files did not have competency evaluations. During an interview on 09/15/2011 at 11:30 a.m., the CEO and the assistant administrator confirmed the facility uses approximately 327.88 hours or about 31 twelve hour shifts of agency staff per month.

Based on observation, interview and record review, the facility failed to obtain a physician order to allow one patient (#1) to use and administer medication brought from home.

Findings included:

During an observation on 09/14/2011 at 12:50 p.m., patient #1 was observed to have a box labeled as Advair 250/50 (inhaler medication used to breathing function). There was no label on the medication showing any review by the pharmacist.
During an interview with on 09/14/2011 at 12:50 p.m., patient #1 said she uses the inhaler herself. She said she brought the medication in from home.
Medical record review for patient #1, admitted on 09/13/2011 with a diagnosis of anemia showed the physician order dated 09/13/2011 at 1:00 p.m. for Advair 250/50 one puff BID (two times daily). The order did not state use medication from home or allow patient to administer own medications. Review of the Medical Staff Rules and Regulations dated December 2009 state-Drugs brought into the hospital by a patient may not be administered unless the drugs have been identified and there is a written order from the attending Practitioner to administer the drugs and the drug is not available from the pharmacy. Self-administration of medication is not permitted.
During an interview on 09/14/2011 at 1:00 p.m. the director of nursing said the physician order should include leaving the medication at the bedside.

Based on interview and record review, the facility failed to ensure the physician authenticated protocol orders for 2 of 10 patients (#2 & #9); and failed to ensure the physician counter-signed orders written by the advanced registered nurse practitioner (ARNP) within forty-eight hours for 1 of 10 patients (#9).

Findings included:

Review of the Medical Staff Rules and Regulations approved December 2009 state-All clinical entries in the patient's medical record must be accurately dated and timed and individually authenticated by the responsible staff member upon his/her next visit to the hospital. Authentication shall be a written signature, identifiable initials or computer key (electronic signature). Also-For those entries requiring counter -signatures, to include those make by physician assistants, and advance practice registered nurse practitioners, the responsible medical staff shall sign such progress notes the same day and orders within forty-eight (48) hours.
Medical record review for patient #2, admitted on 09/09/2011 with a diagnosis of abdominal pain and dementia, showed an order for a protocol called Adult Electrolyte Replacement and a protocol called Hypoglycemia Treatment (used to order insulin therapy) dated 09/09/2011 and timed at 11:00 p.m. Review of the medical record on 09/14/2011 showed neither protocol had been signed by the physician.
Medical record review for patient #9, admitted on 09/08/2011 with a diagnosis of acute abdominal pain with ascites showed an order for a protocol called Adult Electrolyte Replacement dated 09/10/2011 at 7:50 p.m. Review of the medical record on 09/14/2011 showed the protocol as signed by the physician, however, it was not dated or timed so there was no way of knowing when the order was reviewed and signed by the physician.
Medical record review for patient #9 also showed an order written by the ARNP, dated 09/09/2011 at 10:10 a.m. for treatments, lab testing and medication orders and an order dated 09/12/2011 at 10:15 a.m. for treatments, blood product administration and medication orders. Review of the medical record on 09/15/2011 at 11:15 a.m. showed neither order had been reviewed or counter-signed by the supervising physician.
Review of the credentialing file for the ARNP writing orders for patient #9 showed the Core Privileges as-Write orders per protocol in patient charts for review and countersignature of supervising physician. During review of the medical record on 09/14/2011 at 1:00 p.m. the director of nursing confirmed verbal orders should be countersigned by the physician within forty-eight hours.