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Based on interview and record review, the hospital failed to ensure the performance evaluations were conducted annually for RN 3, RN 4, LVN 2, LVN 3, and CNA 2 as per the hospital's P&P. This failure created the increased risk of unsafe care for the patients receiving services in the hospital.

Findings:

Review of the hospital's P&P titled Core: Evaluation & Verification of Competency dated June 2023 showed the purpose includes to provide a method to measure the employee's performance based on the objective data and to validate competency on an ongoing basis. A summary of the employee's initial and ongoing competency validation is maintained in the employee ' s education file. The annual competency validation section showed the competency is an ongoing process and is achieved at least annually or more frequently if the needs indicate or are required by the regulatory agency. Annual skills are ongoing and should be completed throughout the given year.

Review of the Employee Handbook (undated) showed the site management team may conduct an evaluation near the completion of the introductory period and after that once a year.

On 8/23/24 at 1206 hours, an interview and concurrent record review was conducted with the COO/CCO and Education Manager.

Review of the personnels' files for RN 3, RN 4, LVN 2, LVN 3, and CNA 2 showed the following:

* Review of RN 3's personnel file showed RN 3's DOH was 5/17/16, and the annual performance evaluation was compleleted on 6/7/22. RN 3's personnel file failed to show documented evidence the performance evaluation was conducted for the year 2023 as per the hospital's P&P.

* Review of LVN 2's personnel file showed LVN 2's DOH was 3/8/22, and the performance evaluation was compleleted on 6/9/22. LVN 2's personnel file failed to show documented evidence the performance evaluation was conducted for the year 2023 as per the hospital's P&P.

* Review of CNA 2's personnel file showed CNA 2's DOH was 8/27/01, and the performance evaluation was compleleted on 6/16/22. CNA 2's personnel file failed to show documented evidence the performance evaluation was conducted for the year 2023 as per the hospital's P&P.

* Review of RN 4's personnel file showed RN 4's DOH was 10/25/22. However, RN 4's personnel file did not show any documented evidence of the performance evaluations.

* Review of LVN 3's personnel file showed LVN 3's DOH was 9/20/22. However, LVN 3's personnel file did not show any documented evidence of the performance evaluations.

An 8/23/24 at 1453 hours, the Education Manager was informed and acknowledged the above findings.

On 8/23/24 at 1619 hours, a follow-up interview was conducted with the COO/CCO and Education Manager. They were asked if the policy was followed. The COO/CCO and Education Manager reviewed the hospital's P&P and Employee handbook, and stated no. They were informed and acknowledged the findings.