HospitalInspections.org

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Based on record review, policy review, and interview, the facility failed to ensure fingerprint-based criminal background checks were current (screening renewed every 6-years) as required by hospitals federally certified in the State of Alaska for (4) (#s 1; 9; 18; and 20) of 27 employee records reviewed. There was 1 (#10) employee whose missing initial finger print screening results had not been followed up on since being sent in on 5/2014. In addition, the facility failed to have a system in place that met the State of Alaska's criminal background check requirements (7AAC 10.900 - 7AAC10.990) for employees with direct contact with patients and/or patients' health information working in the health facilities. These failed practices placed vulnerable patients at risk for abuse or neglect. Findings:

Record review on 9/3/15 at 8:00 am of employee personnel records for hospital Staff #s 1; 9; 18; and 20 revealed they had background checks that had lapsed past the every 6-year State of Alaska renewal requirement.

Staff #1's criminal background check had last been completed on 10/13/2007, which was 1 year and 11 months past the 6-year requirement for renewal. Staff # 9's criminal background check had last been completed on 1/25/2005, which was 4 years and 9 months past the 6-year requirement for renewal. Staff # 18's criminal background check had last been completed on 11/17/2007, which was 1 year and 10 months past the 6-year requirement for renewal. Staff # 20's criminal background check had last been completed on 6/7/2007, which was 1 year and 3 months past the 6-year requirement for renewal.

Further personnel record review revealed Staff #10's, date of hire 5/19/2014, had fingerprints done on 5/2/2014 but no results had been received since initially submitting them to the Department of Public Safety 1 year and 4 months ago.

Review of The hospital's "Background and Character Check Policy", dated 3/25/15, pertaining to criminal background screening did not specifically require all employees working with patients' and/or having access to patients' medical record information to have fingerprint based screenings.

During interviews on 9/3/15 at 8:00 am - 9:00 am with the hospital's human resource personnel disclosed for employees working under the Alaska Native Tribal Health Consortium (ANTHC) (which included hospital employees) their staff criminal background checks were done through the Department of Public Safety. The ANTHC human resource staff were unaware criminal background checks were required every 6 years.

Further interviews on 9/3/15 from 8:00 - 9:00 am the ANTHC human resource personnel and the Vice President of Quality disclosed the physicians hired directly by the hospital were not required to have criminal background checks by finger print screening through State and Federal entities. The hospital conducted work history checks, professional licensing reviews and name checks on their physicians. Review of the hospital's physicians list revealed there were 121 active physicians (MDs) working for the hospital, and there were 164 MDs that were either consultants or associated/affiliate with the hospital. As a result, there were 285 physicians who potentially could have had criminal backgrounds that could have placed vulnerable patients at risk.

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Based on record review and interview, the facility failed to ensure complete care plans for 2 identified patients, (#s 5 and 15) Specifically, no individualized care plans were completed for these patients during their hospital stay. This placed these patients at risk of not having the level of care and comfort measures they required. Findings:


Patient #5


Record review from 9/2-4/15 revealed Patient 5 was admitted to the facility on 3/8/15 with diagnoses that included subdermal hematoma (a collection of blood outside the brain that is usually caused by severe head injuries) and a fracture of the right temporal bone (base of the skull). Further review revealed Patient 5 was discharge on 3/10/15.


Review of the nursing care plan for the period 3/8/15-3/12/15 revealed the following identified problems:
1) Long Term Goal(By Discharge):Client reports risk factors to infection
2) Reduce pts susceptibility to infection
3) Use appropriate Universal Precautions.


Patient #15


Record review from 9/2-4/15 revealed Patient 15 was born at the facility on 5/2/15 with diagnoses that included hypoplastic left heart syndrome (a complex and rare heart defect where the left heart is critically undeveloped), was then transferred to another facility on 5/2/15 at 6:00 am and then readmitted back to the facility on 5/2/15 at 4:48 pm for comfort care. Patient 15 later died at the facility on 5/4/15 at 7:22 pm.


Review of the nursing care plan for the period 5/2/15-5/6/15 revealed the following identified problems:
1) Long Term Goal(By Discharge):Client reports risk factors to infection
2) Reduce pts susceptibility to infection
3) Use appropriate Universal Precautions.


No individualized nursing care plans were identified for Patients' 5 and 15 related to their treatments, goals, physiologic or psychosocial factors/needs.



During an interview on 9/3/15 at 1:45 pm Staff #3 stated there was no further care plans for Patients' 5 and 15. Staff #3 further stated she did not know why individual care plans weren't done.

During an interview on 9/4/15 at 9:45 am, Staff #4 stated there was no other care plans developed for Patients' 5 and 15 during those episodes of care.


Review on 9/4/15 at 10:00 am of the facilities policy with a revision date of 11/13, revealed "NURSING SERVICES ADMINISTRATIVE PROCEDURES ...INTERDISCIPLINARY PATIENT PLAN OF CARE ...Contains measurable patient care goals and/or desired outcomes ...will be revised and updated by an RN, no less than once every 12 hours..."

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