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Based on review of the North Carolina General Statutes (N.C.G.S.), facility list of agency nursing staff, nursing pool contracts and staff interviews, the facility staff failed to ensure 2 of 4 nursing pool agencies (Agency #5 and Agency #6) were licensed as required in the state of North Carolina, pursuant to the N.C.G.S.

The findings include:

Review of N.C.G.S. §131E-154.3 titled, "Licensing", last updated on September 27, 2019, revealed, (a) No person shall operate or represent himself to the public as operating a nursing pool without obtaining a license from the Department.

Review on 03/03/2020 of a list of agency nurses currently working at the facility revealed a total of eight registered nursing staff working with a total of four listed agencies. Review of the list revealed two registered nurses that were working at the facility from Agency #5 and one registered nurse who was working at the facility from Agency #6.

Interview with CNO #2 on 03/04/2020 at 1450 revealed the nurses from Agency #5 and Agency #6 were working as staff nurses full time, three days per week.

Review on 03/04/2020 of a contract between Agency #5 and the hospital, signed on 01/14/2019, revealed RN #7 was assigned to work at the facility as a registered nurse with a start date of 11/15/2019 and completion date of 02/20/2020. Review revealed the contract was renewed for RN #7 with a start date of 02/21/2020 and completion date of 03/25/2020. Review of the contract revealed the agency was located in Michigan.

Review on 03/04/2020 of a contract between Agency #5 and the hospital, signed on 10/10/2019, revealed RN #8 was assigned to work at the facility as a registered nurse with a start date of 11/15/2019 and completion date of 02/13/2020. Review revealed the contract was renewed for RN #8 with a start date of 02/21/2020 and completion date of 03/25/2020. Review of the contract revealed the agency was located in Michigan.

Review on 03/04/2020 of a contract between Agency #6 and the hospital, signed on 10/08/2018, revealed RN #9 was assigned to work at the facility as a registered nurse with a start date of 10/15/2018 and completion date of 01/12/2019. Review revealed the contract was renewed for RN #9 with a start date of 01/20/2019 through 04/13/2019, and renewed again from 04/14/2019 through 07/13/2019. Review revealed the contract was renewed for RN #9 on 02/06/2020 with a start date of 02/09/2020 and completion date of 03/07/2020.

Interview with CEO #4 on 03/04/2020 at 1450 revealed he was not able to obtain the North Carolina Nursing Pool licenses for Agency #5 and Agency #6. CEO #4 reported that he had talked with Agency #5 and was told that the agency submitted paperwork for a North Carolina Nursing Pool license on 03/04/2020 after he requested a copy of their license. Interview revealed the CEO had not verified a valid North Carolina Nursing Pool license when using nursing pool agencies and was not aware that nursing pools had to have a North Carolina license.

Based on review of the facility job description, personnel file review, and staff interviews, the CNO failed to have a current North Carolina Nursing license.

Findings include:

Review on 03/04/2020 of the facility job description titled, "Chief Nursing Officer" with a revision date of 03/21/2016 revealed, "Qualifications: ... *Up to date Nursing license in the state ...

Review on 03/03/2020 of the "Nursing Service Organizational Chart" revealed "All Nursing Staff, CNA's (Certified Nursing Assistants), Unit Clerks, Monitor Techs, Dieticians (sic) report directly up to the House Supervisors. The House Supervisors report directly up to Clinical Coordinator who report directly to the CNO (Chief Nursing Officer).

Review on 03/04/2020 at 1615 of the personnel files for CNO (Chief Nursing Officer) #2 revealed a current Florida Registered Nurse license, with "Single State" listed for Compact status. Review revealed no evidence of a North Carolina nursing license for CNO #2.

Interview on 03/04/2020 at 1630 with CNO #2 revealed she did not know that her Registered Nursing license was single state. Interview revealed she thought her license was a multistate compact license.

Based on review of the facility policy and procedures, observations during medication pass, medical record review, and staff interviews, the nursing staff failed to perform hand hygiene with soap and water after providing care for a patient on enteric isolation precautions in 1 of 2 medicine pass observations. (RN #1)

Findings include:

A. Review on 03/03/2020 of the facility policy titled, "Standard Precautions" with a revision date of 07/2019 revealed, "Policy: IC 4-5 Principles ... D. Patients with contagious enteric illness/infections will be placed in Contact Enteric Precautions. Hand hygiene will be done using soap and water ... Procedures ... B. Specific Procedures ... 2 ... If the patient is in contact precautions for an enteric illness such as C-Diff/Norovirus (Clostridium difficile - baterium causes diarrhea)/(infection causing sudden onset of diarrhea and vomiting), then use the Contact Special Enteric Precautions sign to prompt the staff to perform hand hygiene with soap and water ... 5 ... If hands are visibly soiled or if contact special enteric isolation is in place for C-Diff/Norovirus then hand washing with soap and water must be completed ...

Observation during a medicine pass on 03/03/2020 at 1000 revealed RN (Registered Nurse) #1 administered an IV (intravenous - in the vein) push medication and an subcutaneous injection per MD (Medical Doctor)'s orders to Patient #2. Observation revealed there was a "Contact Special Enteric Precautions" sign in the hallway, on the left-hand side of the door to the patient's room. Observation revealed RN #1 removed her PPE (personal protective equipment), used the foam hand sanitizer and exited Patient #2's room. Observation revealed RN #1 did not perform hand hygiene using soap and water.

Medical record review on 03/03/2020 of Patient #2 revealed a 54-year-old male patient admitted on 01/16/2020 with a diagnosis of "Acute Respiratory Failure with Hypoxia". Review revealed Patient #2 had a past medical history of Septic shock and C-Diff.

Interview on 03/03/2020 at 1230 with RN #1 revealed she was not given information in report that the patient was on enteric precautions and she had not had time to read the chart yet. Interview revealed RN #1 knew the patient was on isolation for MRSA (methicillin-resistant staphylococcus aureus) (infection resistant to antibiotics). Interview revealed RN #1 used standard precautions for a patient on contact isolation. Interview revealed RN #1 should have washed her hands with soap and water for the patient who was on Enteric precautions for C-Diff.

Interview on 03/04/2020 at 1248 with RN #3 revealed she was the interim infection control nurse. Interview revealed RN #1 should have washed her hands with soap and water after performing care and removing her PPE. Interview revealed the facility had a training last week regarding hand hygiene, isolation rooms, and using foam verses soap and water. Interview revealed the facility has been using the "secret shopper" (select certain staff, give 5-10-minute training on what to look for, have them identify when they see someone go in or out of an isolation room and not perform hand hygiene or not donning appropriate PPE) method to determine compliance with handwashing and appropriate use of PPE. Interview revealed the facility identified an education need and provided the training last week. Interview revealed the "secret shopper" program has been changed to now identify the person being observed so either training or disciplinary measures can be addressed directly with that individual.

NC00158769