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 review of state law, review of federal regulation, review of hospital personnel file, and staff interview, the hospital failed to follow state licensure requirements by failing to report an unlicensed health care personnel that committed neglect for 1 of 1 sampled personnel files reviewed (MHT #3).

The findings included:

Review of state law 131E-256 Health Care Personnel Registry revealed, "(a) The Department shall establish and maintain a health care personnel registry containing the names of all health care personnel working in health care facilities in North Carolina who have: (1) Been subject to findings by the Department of: a. Neglect or abuse of a resident in a health care facility... For the purpose of this section, the term 'health care personnel' means any unlicensed staff of a health care facility that has direct access to residents, clients, or their property. Direct access includes any health care facility unlicensed staff that during the course of employment has the opportunity for direct contact with an individual or an individual's property, when that individual is a resident or person to whom services are provided... Health care facilities shall ensure that the Department is notified of all allegations against health care personnel..."

Review of federal regulation 42 CFR 488.301 revealed, "...Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness..."

Review of the hospital personnel file of Mental Health Technician (MHT) #3 revealed, "...Termination: Walked off shift 3/19/16 without management approval..."

Staff interview conducted on 05/04/2016 1300 with the Director of Risk Management (DRM), revealed MHT #3's employment was terminated because he abandoned his assigned hall while on duty. Interview revealed he was not reported to the North Carolina Health Care Personnel Registry.

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