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 policy and procedure review, employee file review, North Carolina Board of Nursing (NCBON) license verification website review, and staff interviews the facility staff failed to ensure the Director of Nursing (DON) held a valid NC license to practice as a Registered Nurse prior to beginning employment as the DON.

The findings include:

Review on 10/06/2016 of Policy and Procedure, "SUBJECT: HIRING PROCESS", reviewed/revised 05/24/2016, revealed "...(C) regulated positions must maintain current certification, registration, and/or licensure on a continuing basis and provide proof of such to the Human Resources Department upon hire.... Employees failing to present proof of licensure and/or registration may not be scheduled to work....(D) Evidence of licensure and/or registration must be provided to the Company at the time of hire....Evidence of licensure and/or registration will be maintained in an employee's personnel file. ..."

Review of the Employee File for the DON, on 10/06/2016, revealed a job description for the Director of Nursing. Job description review revealed "...QUALIFICATIONS: Current North Caroina (sic) Licensure... ." Job description review revealed a line for the employee to sign and date, and revealed a handwritten signature of the DON and a handwritten date of 10/03/2016. Review revealed another line for Manager Signature and date, with a handwritten signature of Director # 1 (Dir #1 ) and handwritten date of 10/03/2016. Employee file review revealed a copy of primary source license data for an active RN (Registered Nurse) license in West Virginia, a non-compact state. File review did not reveal any evidence of verification of a RN license in NC.

Review of the NCBON licensure verification website, on 10/06/2016, did not reveal a NC RN license listed for the new DON.

Interview with the DON, on 10/06/2016 at 1430, revealed she had submitted an application for a NC license prior to relocating to NC. Interview revealed the DON thought the license was issued since the application was received, but in contacting the NCBON today learned that it took six to eight weeks for an initial license to be issued. The DON stated the NCBON representative recommended applying for a temporary license which could be issued within five (5) days. The DON stated the temporary license was requested today (10/06/2016).

Interview with Director (Dir) #1, and Coordinator #1 on 10/06/2016 at 1510 revealed Dir #1 was on vacation when the new DON started working at the facility. Interview revealed that prior to leaving for vacation, Dir #1 sent the DON a packet to complete and return. Upon return from vacation, Dir #1 stated, the DON was already here, had already started work. Interview revealed Dir #1 was not aware of when the DON was starting work, that had not been finalized prior to vacation. Interview revealed Coordinator #1 was not aware of the start date in advance either. Further interview confirmed the DON did not have a current RN License in North Carolina. Interview revealed hospital policy was not followed.

Interview with the Chief Executive Officer (CEO), on 10/06/2016 at 1545, revealed the CEO was not aware the DON did not have a NC RN license until today. Interview revealed the CEO told Dir #1 to follow the normal processes and did not know the license was not in place. Interview confirmed policy was not followed.

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