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Based on interview and record review, the Governing Body failed to ensure:

1. The Chief Executive Officer (CEO) fulfilled his duty to develop and maintain personnel practices, and establish internal controls for human resources in the best interest of the hospital when:

a. An agency employee working as a Registered Nurse (RN 1) was not adequately vetted (checked) prior to caring for 1,112 patients in the Emergency Department (ED), and was impersonating an RN (Refer to A0057);

b. An employee working as a Radiology Technologist (RT 1) was not adequately vetted prior to performing 3,295 x-ray procedures on patients at the hospital, and was impersonating an RT (Refer to A0057);

c. Standardized polices, procedures, and practices were not in place for all areas where employees were vetted before beginning their employment (Refer to A0057); and,

2. Quality assessment performance improvement activities were not developed or implemented after the detection of two adverse events (individuals impersonating licensed healthcare workers) (Refer to A0263).

The cumulative effect of these systemic problems resulted in failure of the governing body to ensure care was provided by qualified individuals in a safe and effective manner.

Based on interview and record review, the Governing Body failed to ensure the Chief Executive Officer (CEO) fulfilled his duty to develop and maintain personnel practices, and establish internal controls for human resources in the best interest of the hospital when:

1. An agency employee working as a Registered Nurse (RN 1) was not adequately vetted (checked) prior to caring for 1,112 patients in the Emergency Department (ED);

2. An employee working as a Radiology Technologist (RT 1) was not adequately vetted prior to performing 3,295 x-ray procedures on patients at the hospital.

Both of the employees were discovered (by persons/entities outside of the facility) to be unlicensed individuals who were impersonating licensed health care workers; and,

3. Standardized polices, procedures, and practices were not in place for all areas where employees were vetted before beginning their employment.

This failed practice resulted in the potential for misdiagnosis, mistreatment, harm, or death in patients of all ages.

Findings:

1. During an interview with the Chief Quality Officer (CQO) on July 6, 2017, at 9:15 a.m., the CQO stated RN 1 was working in the ED from February to May 2017. The CQO stated on June 30, 2017, the facility learned, from a news source, RN 1 was impersonating the individual he claimed to be, and did not have a license to work as an RN.

The employment files for RN 1 were reviewed with the CQO on July 6, 2017. The files indicated the following:

a. RN 1 was hired through a temporary agency as a, "traveler," to complete a 13 week assignment in the ED, working full time hours, 7 a.m. to 7:30 p.m;

b. The agency, as part of their contract, provided the following employment documents to the facility prior to RN 1's start date:

aa. An RN job description, signed by RN 1;
bb. A resume that included education and work experience;
cc. Two employment reference checks;
dd. On-line RN license verification;
ee. A copy of the RN license;
ff. A criminal background check that was, "clear;"
gg. A national sex offender search with no findings;
hh. A State of California Identification Card with a picture of RN 1;
ii A physical examination report with a clean drug test; and,
jj. Certifications required to perform the ED RN functions;

c. Upon receipt of the documents, the facility verified the information on the, "Registry/Traveler Attestation," document; and,

d. RN 1 started working at the facility on February 15, 2017, attended hospital and nursing orientation, and completed the facility, "General Information," document (that included demographic and emergency contact information).

A review of Registry Sign-In Sheets indicated RN 1 worked 52 shifts (591.75 hours) between February 15 and May 9, 2017.

A review of patient contacts indicated RN 1 cared for 1,112 patients between February 15 and May 9, 2017.

A review of a letter sent to the facility by the RN Board investigator on July 6, 2017, indicated RN 1 was not a licensed nurse, and was impersonating the individual he claimed to be.

Further review of the employment documents was conducted on July 31, 2017. The review indicated different birthdates were provided by RN 1 on:

aa. The criminal background check (September 14, 1986);

bb. The California (picture) ID card (July 14, 1986);

cc. The physical examination document (April 14, 1986); and,

dd. The facility general information document (September 14, 1985).

The Registry/Traveler Attestation document had a check mark beside each item that was sent by the agency. A statement at the bottom of the page that read, "I have reviewed the above employee's file and attest that the information provided is accurate," was not signed or dated. The document had an area for the, "Staffing Coordinator," to sign and date, and the area was blank.

During an interview with the Director of Staffing (DS) on July 31, 2017, at 10 a.m., the DS stated when the staffing coordinator reviewed the information on the attestation page, they verified expiration on applicable documents. The DS stated the staffing coordinator did not compare or verify any other information, but, "we will now." The DS stated there were discrepancies in the birthdates that should have been identified by the agency and/or the staffing coordinator.

2. During an interview with the Chief Quality Officer (CQO) on September 7, 2017, at 9:45 a.m., the CQO stated RT 1 was working in the radiology department from March 31, 2016, to August 31, 2017 (17 months). The CQO stated the facility received a phone call from an anonymous source on August 30, 2017, indicating RT 1 was impersonating the individual he claimed to be, and did not have a license to work as an RT.

The employment files for RT 1 were reviewed with the CQO on September 7, 2017. The files indicated the following:

a. RT 1 applied for a position as an RT, indicating he was a licensed RT with 11 years of experience at three different hospitals;

b. The application indicated RT 1 graduated form a college with an associate degree;

c. The background check (performed by the facility human resources department) indicated none of RT 1's employment could be verified, with no additional efforts by the human resources department to verify the information;

d. The background check attempt to verify his education indicated, "The registrar's office was unable to locate any record of this student. No records were found under Name, SSN (social security number), or DOB (date of birth). NOTE: School did not offer radiology;" and,

e. The background company spoke to the applicant and he stated, "AA in Radiology at (name of college). My records may be frozen due to payment."

There was no evidence of further attempts by the human resources department to verify RT 1's education.

The CQO stated the person in human resources who processed RT 1's pre-employment information was new to the department and covering for somebody who was on a leave of absence.

Review of a patient procedure report indicated RT 1 performed 3,295 x-ray procedures on patients in the facility during his employment.

3. a. A review of the human resources policy and procedure index was conducted on September 7, 2017. The review indicated there was no policy or procedure regarding the pre-employment process for employees in the human resources department or the staffing office to follow, and there was no policy or procedure regarding the information to be verified and/or questioned on a background check.

The Human Resources, "Scope of Service," document was reviewed on November 15, 2017. The document indicated Human Resources would work with department directors and managers to provide adequate numbers of competent staff when and where needed, and would conduct initial employee screening.

The Governing Body Bylaws were reviewed on November 15, 2017. The bylaws indicated the following:

aa. The Board would select and appoint a CEO;

bb. The CEO would be the representative of the Board in the operation of the hospital;

cc. CEO duties included selecting, employing, controlling, and discharging employees and developing and maintaining personnel policies and practices of the hospital; and,

dd. CEO duties included establishing internal controls for....human resources.

The Governing Body meeting minutes were reviewed on November 15, 2017. The minutes indicated the Governing Body was made aware of the individuals impersonating licensed health care workers, by the Chief Executive Officer (CEO) and the CQO, at meetings held on July 27 and September 27, 2017. The minutes further indicated the members discussed ways to avoid the adverse event from happening in the future, and they were told the process in Human Resources would be changed.

During an interview with the Chief Quality Officer (CQO) and the Vice President of Human Resources (VPHR) on November 15, 2017, at 9:30 a.m., they stated they had not developed any policies or procedures regarding the pre-employment process or the background check (initially or since the health care worker impersonators had been discovered).

During an interview with the Director of Staffing (DS) on November 15, 2017, at 1:30 p.m., the DS stated they had not developed any written policies or procedures for the staff to follow regarding the pre-employment process or the background check. The DS stated they received different documents from different agencies, and there was no standard set of information that was received.

During an interview with the Senior Human Resources Generalist (SHRG) on December 15, 2017, at 1:50 p.m., the SHRG stated the Talent Acquisition Specialist (TAS) usually processed the pre-employment documents of applicants. The SHRG stated she processed new hires when the TAS was on vacation. The SHRG stated there had been "a binder years ago" which contained the procedure for the pre-employment processing of new hires in the absence of the TAS. The SHRG stated she was not sure if the binder was up to date. The SHRG stated she did it so often and had been doing it for so long, she would, "do it by memory."

During an interview with the TAS on November 15, 2017, at 2:25 p.m., the TAS stated she was on leave when RT 1 was hired, and the person covering for her (a Human Resources [HR] Assistant) processed the RT 1's pre-employment file. The TAS stated they did not have a written policy or procedure regarding the pre-employment process or background checks to be followed within the human resources department or staffing office. The TAS stated the HR assistant who covered for her did not have a documented procedure to follow to ensure the hiring process was done thoroughly.

According to the TAS, information sent to the background agency (used to request a background check) was taken from a form filled out by the potential employee. She stated they did not use any form of official identification to submit the background request.

The TAS further stated HR staff did not compare the potential hire's date of birth to the information listed on the background check form they received. The TAS stated if there were discrepancies on the background check results they received, HR staff called the potential hire to clarify the information.

The TAS stated the first and only time they used potential hire's picture ID was to compare it to the hand-written I-9 form (a US Citizenship and Immigration Services form used to verify identification and employment authorization) that the potential hire filled out, and that was done after the employee had already been offered a position.

b. On November 16, 2017, beginning at 9:45 a.m., a random sample of employee files were reviewed. The file for Echocardiogram Tech (ET) 1 was reviewed, and included various documents signed by ET 1, dated September 8, 2017. The file contained education certificates and a brief, single page, criminal background check form (instead of the multiple page document with verification of demographic, employment, and education information required for employees processed through the HR department). There was no documentation in the file to indicate any of the forms, including the background check form, had been reviewed or verified by facility staff. There was no documentation included in the file that specified ET 1's position at the facility, the date of hire, or where the pre-employment documents came from.

On November 16, 2017, at 11:30 a.m., the HRVP and the SHRG were interviewed. The HRVP and the SHRG stated ET 1 was a, "contract agency," employee who worked at the facility when the regular echocardiogram tech was not available. The HRVP and the SHRG stated ET 1 was hired on September 7, 2017, and signed documents in the Human Resources department on September 8, 2017. The HRVP and the SHRG stated they did not know why the background check results for ET 1 were in a different format than the background check results seen in other employee files. The HRVP and the SHRG stated the owner of the contract agency would have requested the background check, and the facility would accept the documents he provided, with no questions.

c. On November 16, 2017, at 11:10 a.m., the personnel file of Registered Nurse (RN) 2 was reviewed with the VPHR and the SHRG.

RN 1 was hired to work in the facility on October 18, 2017. Further review of RN 2's employment documents revealed different birthdates were indicated on RN 2's California driver's license [May 5, 1974] and on the background check under the "SSN (Social Security Number) Trace" section [April 8, 1974]. The background check indicated "complete" for the SSN Trace section.

During a concurrent interview, the SHRG stated RN 2's date of birth on the background check did not match the date of birth on RN 2's California driver's license, as well as the date of birth provided by RN 2 on other employment documents.

Based on interview and record review, the facility failed, for two adverse events (individuals impersonating licensed health care workers), to ensure:

1. The events were analyzed to determine their cause (Refer to A0286);

2. Preventive actions were implemented (Refer to A0286);

3. Quality indicators were implemented and monitored (Refer to A0286); and,

4. Staff involved in the hiring process were provided with training (Refer to A0286).

The cumulative effects of these systemic problems resulted in failure to ensure quality care was being provided by qualified individuals in a safe and effective manner.

Based on interview and record review, the facility failed, for two adverse events (individuals impersonating licensed health care workers), to ensure:

1. The events were analyzed to determine their cause;

2. Preventive actions were implemented;

3. Quality indicators were implemented and monitored; and,

4. Staff involved in the hiring process were provided with training.

These failed practices resulted in the potential for reoccurrence of the adverse events, and the potential for misdiagnosis, mistreatment, harm, or death in patients.

Findings:

The, "2016-2017 Quality Assessment Performance Improvement Plan," was reviewed on November 15, 2017. The plan indicated the following:

a. The purpose was to provide a mechanism to monitor patient safety and evaluate quality of services provided to patients;

b. The objectives included integrating quality, safety, and service into performance improvement opportunities, implementing actions, and evaluating results;

c. The core values included providing an environment that emphasized safety for patients;

d. Areas of focus included improving patient safety, quality, and service;

e. The plan was, "flexible to accommodate...unusual events."

The plan further indicated, "Objectives and topics can be introduced at any time to be prioritized and included in the scope of the Quality and Patient Safety Plan."

The facility experienced two adverse events that were discovered on June 30 and August 30, 2017:

1. An agency employee worked as a Registered Nurse (RN 1) and provided care to 1,112 patients in the Emergency Department (ED); and,

2. An employee worked as a Radiology Technologist (RT 1) and performed 3,295 x-ray procedures on patients at the hospital.

Both of the employees were discovered (by persons/entities outside of the facility) to be unlicensed individuals who were impersonating licensed health care workers.

(Refer to A0057)

The Governing Body meeting minutes were reviewed on November 15, 2017. The minutes indicated the Governing Body was made aware of the individuals impersonating licensed health care workers, by the Chief Executive Officer (CEO) and the CQO, at meetings held on July 27 and September 27, 2017. The minutes further indicated the members discussed ways to avoid the adverse event from happening in the future, and they were told the process in Human Resources would be changed.

The quality indicator data presented at the Governing Body meetings was reviewed. There was no evidence of any quality indicators, data collection, or monitoring being done regarding the pre-employment process.

During an interview with the Chief Quality Officer (CQO) and the Vice President of Human Resources (VPHR) on November 15, 2017, at 9:30 a.m., they stated they had not developed any policies or procedures regarding the pre-employment process or the background check. The VPHR stated she would be cross-training all staff in the human resources department to do the pre-employment process, so if somebody had to cover in another persons absence, they would know how to do the job. The VPHR stated the cross-training had not started yet.

During an interview with the Director of Staffing (DS) on November 15, 2017, at 1:30 p.m., the DS stated they had changed their procedures in the staffing office. The DS stated they now had to double check information on all of the pre-employment documents they received. The DS stated they had not developed any written policies or procedures for the staff to follow regarding the pre-employment process or the background check. The DS stated they received different types of documents from different agencies to review for potential hires, and there was no standard set of information that was received. She stated she was not doing data collection, analysis, or reporting on the process in the staffing office.

During an interview with the Senior Human Resources Generalist (SHRG) on December 15, 2017, at 1:50 p.m., the SHRG stated they had discussed the importance of double-checking information and, "being more firm," when they reviewed potential hires' background checks within the human resources department. The SHRG stated she processed new hires when the person who usually performed the task was on vacation. She stated she did not know if they had an up to date procedure in the department. The SHRG stated she did it so often and had been doing it for so long, that she would, "do it by memory."

During an interview with the Talent Acquisition Specialist (TAS) on November 15, 2017, at 2:25 p.m., the TAS stated she was on leave when RT 1 was hired, and the person covering for her processed RT 1's employee file. The TAS stated they had discussed how to prevent errors from happening again within the department, and if they could not verify an item on the background check, they would take the information to the VPHR. The TAS stated they were going to cross train the employees in the human resources department so everybody could, "be on the same page," but they had not yet. She stated she would go to the VPHR and get a second opinion, based on her experience, and if her, "gut," told her to. The TAS stated they did not have a written policy or procedure regarding the pre-employment process or background checks to be followed within the human resources department or staffing office.

During an interview with the CQO on November 16, 2017, at 9:30 a.m., the CQO stated there was no analysis of the adverse events, no quality improvement plan implemented, and no data being collected, monitored, or reported by the facility.

During an interview with the Governing Body members on November 16, 2017, at 1:30 p.m., Governing Board Member 1 (GBM) 1 stated when they were told about the individuals impersonating licensed healthcare workers, they took it very seriously. GBM 1 stated they had a discussion regarding some things that could be done to prevent, "it," from happening again, and she believed they would be presented with a plan developed by facility staff to address the problems at the next meeting. GBM 1 stated she was unable to attend the next meeting, so she did not know whether a plan was presented.

During an interview with the CQO on November 16, 2017, at 2:15 p.m., the CQO confirmed there had not been a quality improvement plan, related to the hiring process or the adverse events, developed or implemented by the facility.