HospitalInspections.org

The CAH has a governing body or an individual that assumes full legal responsibility for determining, implementing, and monitoring polices governing the CAH's total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment.

This STANDARD is not met as evidenced by: Based on document review and interviews with key personnel on December 3, 2014, it was determined that the Chief Executive Officer failed to ensure that all facility polices were followed.

The findings Include:

1. The Recruitment and Hiring Process policy states; "5. Human Resources submits the screenings request through eHire-Universal Background Screening and records the order number and date ... 6. Once the background screen comes back it is forwarded to the department manager. Once they approve this, an offer letter is drawn up ..."

2. A review of twelve (12) personnel files was conducted. Six (6) of the personnel surveyed were hired after October 1, 2010, therefore requiring a criminal background check be conducted before hire.

3. Three (3) of the six (6) employees hired after October 1, 2010, [employees 2, 6, and 12], the personnel files failed to contain evidence of a Criminal Background check performed before the employee was hired and started working.

4. These finding were confirmed with the Human Resources Manager on December 3, 2014 at 11:00 AM. She stated that she recently took over the Department, and that she was aware of the requirement, however; she was not aware that in the interim between Department Managers some employees were hired without a Criminal Background checks completed.

Based on record review and interview with key personnel on December 2 & 3, 2014, it was determined that the facility lacked evidence that the patient's received a written notice of their rights prior to receiving services in the facility, for three (3) sampled swing bed patients, (Record GG, HH and II).

Findings include:

1. The medical records (Record GG, HH and II), for sampled swing bed patients, lacked evidence that the patient's had received written notice of their rights prior to receiving services in the facility.

2. This finding was confirmed by the Nurse Manager of Inpatient and Emergency Department on December 2, 2014 at approximately 2:10 PM.

Based on record review and interview with key personnel on December 3, 2014, the facility failed to ensure that the written notice of discharge/transfer was included in the medical record of two (2) discharged swing bed patients (Record N and O).

Findings include:

1. The medical records of two (2) discharged swing bed patients (Record N and O) lacked evidence that a letter of discharge/transfer was given to the patient/family prior to discharge.

2. This finding was confirmed by the Chief Nursing Officer and the Nurse Manager of Inpatient and Emergency Department on December 3, 2014 at approximately 1:10 PM.