The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based on staff interview, personnel file review, facility document review, and in the course of a complaint investigation, it was determined the facility staff failed to verify the license status of an employee before issuing a registered nurse (RN) name badge.

The findings include:

Employee #1 worked at the facility in a different capacity, until finishing nursing school in May 2012. The facility's usual practice was to not allow an employee to work in their former role, if there was a time gap between taking/passing the NCLEX (nursing board exam) and starting orientation as an RN (registered nurse).

Employee #1 worked in the operating room area (OR) which started orientation for newly hired RNs four (4) times per year. OR orientations for RNs began in May and August 2012.

The surveyor interviewed Employee #2, a nurse educator for the OR; on 8/5/12 at 9:40 a.m. Employee #2 explained the facility did not want to potentially lose Employee #1, if there was a gap between the employee passing the nursing board exam and the start of RN orientation (PeriOp 101) in August 2012. The nurse educator stated a decision was made with the administrator, director, and with the approval of the facility CNE (chief nursing executive) to have Employee #1 start RN orientation in May 2012, as long as the orientation only involved classroom training only, and no actual patient care. It was known Employee #1 planned to take the NCLEX at the end of June 2012.

Employee #1, started RN orientation in the hospital wide orientation, as any other newly hired nurse. During the orientation, the employee was given a new badge which included the employee's name and identification as an RN. The nurse educator stated she did not notice the change in status on the badge immediately and when she did, she addressed it with Employee #1, asking the employee to return to wearing the former badge for surgical technician (ST).

The OR Administrator and Director met with the surveyor on 9/5/12 at 10:52 a.m. Both described an exception to the usual facility practice of only having RNs in the PeriOp 101 class. Employee #1 was allowed to start the PeriOp 101 class, though having not taken, nor passed the NCLEX exam. Both acknowledged the employee wore an RN badge, though the employee was not an RN.

Both stated the Human Resource department prepared badges and they were distributed during hospital orientation. The administrator stated, "He (Employee #1) simply didn't think about it", regarding the wearing of a badge for an RN. The nursing educator, administrator, and director all stated Employee #1 did not wear the larger orange badge that included "RN" and was a clear distinction from badges of other employees. The administrator stated she thought the employee wore the new RN badge because his old badge was deactivated and would not allow access to doors/money for the cafeteria, etc.

The surveyor interviewed Employee #1 on 9/5/12 at 11:22 a.m. The employee explained he had completed nursing school in May 2012. To avoid the potential of being out of work between passing the NCLEX and the start of RN orientation in August 2012, an arrangement was made for him to start in the PeriOp 101 classroom training in mid-May; with the understanding he would not do clinical work until passing the NCLEX.

The employee stated he initially went to the hospital orientation as all new RNs would do. At the orientation, he was given a badge which included the title of registered nurse. He informed the surveyor he was also given the larger orange badge which included "RN". The surveyor had observed the orange badges on RN nursing staff throughout the facility. No other disciplines wore the additional badge. The RN on the orange badge could be clearly read from a distance and the orange color helped to identify the RN staff.

The employee acknowledged he wore the RN badge, in part, because his old one was deactivated when he was given the new one. He also stated it was "kind of a grey area" for him to take the PeriOp 101 class without being an RN. He thought that if it had been arranged by managers, then it was okay to wear the RN badge. When the time came for the clinical portion of the PeriOp 101 class and Employee #1 was not yet an RN, he returned to surgical technician status, sometime in July 2012. He stated that he continued to wear the RN badge for approximately a week after returning to ST status because it took some time for his old badge to be re-activated.

The surveyor reviewed the personnel file for Employee #1 on the afternoon of 9/5/12. Other personnel files for RNs included a license verification form from the Department of Health Professions (DHP). Employee #1's file did not include verification with DHP.

Two human resource (HR)/recruitment managers were present during the review of the personnel files. They explained the process for new hires, transfers or employees being promoted. The HR department, manager and employee discussed dates of NCLEX exams, and potential dates for orientation. Part of the process includes RN license verification with DHP. And, a list of nurses was given to the ID office that created the name badges. Current employees may use the same picture for new badges. New employees have pictures taken when paperwork is completed prior to the start of orientation. The badges are then given out the first day of orientation. Both managers confirmed that license verification was not done for Employee #1 and an RN badge was given to the employee, though Employee #1 was not an RN.

Both stated this was a unique situation and did not go through the usual process. The recruitment manager stated the process was being reviewed and changes planned, though the plan had not yet been finalized.

The surveyor reviewed the facility policy and procedure titled, "Health care Provider Licensure and Certification". The effective date of the policy was 7/1/10. "All applicants for positions that require licensure, certification or registration shall provide to Human Resources proof of current licensure, certification or registration, or licensure/certification/registration shall be verified at the source before beginning employment with the Medical Center."