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Based on record review and interview, the facility failed to ensure the patient grievance process was followed and contact was made with the complainants within 7 business days in 5 (patients #36, #38, #39, #40 and #41) out of 6 (patients #36, #37, #38, #39, #40 and #41) grievances reviewed.
A review of 5 (patients #36, #38, #39, #40 and #41) out of 6 (patients #36, #37, #38, #39, #40 and #41) written "Complaint Records" revealed the facility did not make contact with the complainants within 7 business days to acknowledge receipt of the grievances.
A review of the facility's policy titled, "Complaint and Resolution Process" revealed the following information:
" ...The patient, a family member or the responsible party will be contacted within 7 business days of the concern, complaint or grievance received in writing to document the contact, to acknowledge receipt of the concern, complaint or grievance and/or answer the complaint.
An interview with staff #6 and #39, confirmed the above findings.

Based on record review, document review and interview, the facility failed to ensure the patient grievance process was followed and a final written response was sent to the complainant within 30 business days in 1 (patient #40) of 6 (patients #36, #37, #38, #39, #40 and #41) grievances reviewed.
Review of patient #40's Complaint Record revealed the written grievance was received by the facility on 02/25/2016. The final resolution letter was sent to the complainant 51 business days later on 05/06/2016.
A review of the facility's policy titled, "Complaint and Resolution Process" revealed the following information:
" ...The final written response must be sent to the complainant within 30 business days."
An interview with staff #6 and #39, confirmed the above findings.

Based on record review and interview the Chief Nursing Officer failed to:

A. ensure all nursing staff had current competencies and were qualified by education to perform invasive procedures. These findings had the likelihood to cause harm to all patients receiving care at the facility by failure to ensure staff were competent. Citing 5 (#11, #12, #13, #21 and #22) of 6 (#11, #12, #13, #14, #21 and #22) personnel records for staff working on the hemodialysis unit.

B. provide clear lines of authority and responsibility for staffing of the Observation Unit.


A. Findings:

Review of the facility policy Competency Assessment #200.141, 3. "Competency will be assessed annually by: a. Performance evaluation. b. Completion of unit specific self-assessment and manager/peer validation. c. Continued licensure, registration or certification. d. Annual fit testing. e. Learner paced modules and post-test, as appropriate. f. Return demonstration."

Review of staff #11's personnel record revealed the competencies were last evaluated in May 2014.

Review of staff #13's personnel record revealed the competencies were last evaluated in May 2014. In addition, staff # 13 was an unlicensed technician and was allowed to cannulate AV Fistulas and AV Grafts; there was no evidence of training by the facility. An interview with staff # 10 on 05/17/2016 at 4:30 p.m. confirmed there was no policy approved by the Chief Nursing Officer and Governing Body of the Hospital to allow unlicensed technicians to cannulate accesses.

Review of staff #11's personnel record revealed there were no documented competencies in the personnel file. In addition staff #11 was an unlicensed technician and was allowed to cannulate AV Fistulas and AV Grafts; there was no evidence of training by the facility. An interview with staff #10 on 05/17/2016 at 10:30 a.m. confirmed there was no policy approved by the Chief Nursing Officer and Governing Body of the Hospital to allow unlicensed technicians to cannulate accesses. There also was no evidence staff #11 had taken CPR.

Review of staff #21's personnel record revealed the competencies were last evaluated in June of 2013. In addition the CPR expired in February 2016.

Review of staff #22's personnel record revealed the competencies were last evaluated in October 2013. In addition the CPR expired in February 2016.

Interview with staff # 10 on 05/17/2016 at 4:30 p.m. confirmed the above findings.





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B. Findings.

Review of Emergency Department staffing records showed that nurses from the Emergency Department were assigned on a regular basis to staff a unit of the hospital, the Observation Unit, which is not part of the Emergency Department.

An interview with Staff #66 was conducted on the morning of 5-16-2016 in the Emergency Department. Staff #66 stated there was an Observation Unit that had been created for patients whose treatment in the Emergency Department was completed and were admitted to the hospital in Observation Status. The Observation Unit was started November 1, 2015. The Unit is run by another director from the hospital and staffed during the daytime shift with hospital staff.

During the night shift, 7:00 PM to 7:00 AM, the Emergency Department is required to staff the Observation Unit with two nurses. Staff #66 stated she is responsible for the employees on night shift. At night, a minimum of two staff members were provided. Should a problem arise on the night shift, her employees should notify both her and the Observation Unit director, depending on what the problem was. Staff #66 stated that the Observation Unit director had authority over the unit.

Review of the hospital organizational chart showed that the Observation Unit does not appear on the organization chart. Review of Emergency Department Staffing Matrix does not specify dedicated nurse staffing for a hospital Observation Unit.

Based on record review and interview the facility staff failed to ensure that they had a procedure in place to ensure hospital nursing personnel had a current and valid license. These findings had the likelihood for an unlicensed nurse to obtain employment and care for patients. Citing 3 (#12, #21 and #22) of 3 (#12, #21 and #22) Registered Nurse files reviewed from the hemodialysis unit.

Findings:

Review of the Texas Board of Nursing website Texas Nursing Bulletin Volume 39, No 3 dated July 2008 stated "After September 1, 2008 Nurses and employers should go to the agency website at www.bon.state.tx.us and verify licenses on line. The verification, once printed, will resemble a license and will allow the nurse to have the documente laminated for the purpose of carrying the license with them."

Review of nursing personnel records for staff # 12, #21 and #22 the facility had only verified the nurse's licensure status at the Texas State Board of Nursing web site by searching the nurse's name. The site was not searched by either license number or Social Security Number and date of birth, in order to verify that the nurse working was the same licensed nurse found on the board site. When the site was searched for a nurse by name only, a list of nurses with that name is all that is available to the person running the verification. In order to obtain the correct nurse's license, the site must be searched by either the license number or social security and date of birth.

Review of personnel record for staff #12 who worked in the dialysis unit revealed there was a list from the board of nursing web site that contained 6 Registered Nurses by her same name. In addition the licenses were expired for all 6 nurses listed. There was no way to tell which of the nurses was working at the facility.

Review of personnel record for staff #21 revealed the copy of the board form ran by name only did not contain a license number. The record also indicated the license listed under this name expired in 01/31/2013. There was no evidence the facility had searched using the above process in order to be sure this was the correct nurse and the license was current.

Review of personnel record for staff #22 revealed the copy of the board form ran by name only did not contain a license number. The record also indicated the license under this name had expired in 10/31/2013. There was no evidence the facility had searched using the above process in order to be sure this was the correct nurse and the license was current.

An interview with staff #10 on 05/18/2016 at 14:30 p.m. confirmed the above findings.