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Based on medical record (MR) review, facility policy and interview with facility staff, it was determined the facility failed to document an adverse event in 1 of 2 medical records reviewed for patients with falls. This did affect Patient Identifier (PI) # 1 and had the potential to affect all patients served by the facility.

Findings include:

Policy #: 600
Title: Electronic Event Reporting
Effective Date: 5/15/19

Purpose

To establish guidelines to report and document certain events involving patients...

Definitions:

Actual event: an event occurred that reached the patient or individual ( ... fall ...).

Policy

... an event report is to be completed for every occurrence which meets the following definition: any happening not consistent with the routine care or operation of the facility, or the desired routine care of the patient ...

1. Submitting An Event Report

... There are 16 forms available for submitting events:

C. Fall

1. PI # 1 was admitted to the facility's on 6/28/19 primary diagnosis of CVA (Cerebral Vascular Accident) with Right Sided Hemiparesis.

Review of the Physician's Progress Note dated 7/9/19 revealed the following documentation: "Patient fell against toilet seat yesterday injuring left hip and complains of pain".

There was no documentation an event report had been completed for 7/19/19 fall event.

An interview was conducted on 9/3/19 at 3:30 PM with Employee Identifier # 1, Director of Quality/Risk Manager, who verified the aforementioned findings.

Based on review of the personnel files, facility Competency Checklist for Registered Nurses (RN) / Licensed Practical Nurse (LPN) and Competency Checklist for Rehab Tech (Technician), facility policy and interviews with the staff it, was determined the facility failed to ensure all staff had competency skills check off form and skills of each employee were observed.

This affected 3 of 5 employee files reviewed and did affect Employee Identifier (EI) #'s 5, 6 and 7 and had the potential to negatively affect all patients served by the facility.

Findings include:

Policy: Competency Assessment
Policy Number: 406
Policy Reviewed Date: 5/15/19

Purpose:

To ensure that qualified staff members not engaged in highly skilled practice without demonstration of adequate knowledge and competence in designated skills within their area of practice. Supervisory evaluation utilizing competency checklists is the process employed to accomplish initial assessment during the orientation process and yearly verification of continuing knowledge and skill.

Policy:

II. Orientation of New Employees

During the orientation process, the new employee will be assessed, reviewed, and evaluated for his or her ability to meet the position requirements...During the competency assessment period, a fully qualified individual in a similar position...will mentor the employee on an on-going basis. Every effort will be made to complete the initial checklist within the first 90 days of employment...

The director/manager is responsible for assuring that department-specific orientation and the initial competency assessment are completed for each new employee...

IV. Competence Assessment/Performance Evaluation

Department Directors/Managers will complete initial evaluations including competency assessments and validations of staff to include a review of the ability to perform specific responsibilities defined in the job description and competency checklist. Competencies are reviewed and updated as needed on an annual basis.

VI. Record Keeping

1. The Human Resource Department will maintain

D. Original of Competency Checklists...

2. The Department Director/manager is responsible for maintaining

D. Copy of Competency Checklist for each employee

3. The employee is responsible for

C. Providing a copy of ...completed competency checklist to their Director/Manager or designee...

VII. Guidelines

2. Each staff member must complete all of the designated competencies...at least annually...

4. Completed competency checklists are submitted to the employee's Department Head...

1. Review of EI # 5, RN, personnel file revealed a hire date of 2/25/19 as an RN and a resignation date of 8/29/19. Further review of the personnel file revealed no documentation a Competency Skills Checklist had been completed.

An interview was conducted on 9/5/19 at 11:10 AM with EI # 2, Human Resource (HR) Director, who confirmed the above mentioned findings.



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2. Review of EI # 6, Rehab Nursing Technician (RNT), personnel file revealed a hire date of 4/29/19 as an RNT. Further review of the personnel file revealed no documentation a Competency Skills Checklist had been completed.

An interview was conducted on 9/5/19 at 11:10 AM with EI # 2 who confirmed the above mentioned findings.

3. Review of EI # 7, RNT, personnel file revealed a hire date of 9/17/18 as an RNT. Further review of the personnel file revealed no documentation a Competency Skills Checklist had been completed.

An interview was conducted on 9/5/19 at 11:10 AM with EI # 2 who confirmed the above mentioned findings.