HospitalInspections.org

Based on document review and interview, the facility failed to comply with an Indiana State Code, requiring a nurse aide registry report of Nurse Aides and other non-licensed employees, for 3 of 3 unlicensed personnel files (N3, N5 and N6).

Findings include:

1. Indiana Code IC 16-28-13-4 indicates Operator of health care facility; request for nurse aide registry report
and limited criminal history Sec. 4. (a) Except as provided in subsection (b), a person who:
(1) operates or administers a health care facility; or
(2) operates an entity in the business of contracting to provide nurse aides or other unlicensed employees for a health care facility;
shall apply within three (3) business days from the date a person is employed as a nurse aide or other unlicensed employee for a copy of the person's state nurse aide registry report from the state department and a limited criminal history from the Indiana central repository for criminal history information under IC 10-13-3 or another source allowed by law.

2. Review of staff N3 (Certified Nursing Assistant), N5 and N6's (unlicensed technicians) personnel files, indicated they were hired on 12/09/19 (N3), 12/14/20 (N5) and 10/27/20 (N6) and lacked documentation of Nurse Aide registry reports.

3. Personnel A2 interviewed on 8/11/2021, at approximately 1730 hours, and stated Nurse Aide registry reports are not performed on technicians, licensed or unlicensed, because licensure of technicians is not required.

Based on document review and interview, the facility failed to provide written notice of complaint/grievance outcome in 1 instance.

Findings include:

1. Review of Policy and Procedure No: RE.11 titled "Complaints and Grievances", issued 4/01/2019, indicated For complaints and grievances the Patient Rights Advocate will contact the complainant with the investigative findings within one business day, unless extenuating circumstances arise.

2. Review of Grievance/Complaint log indicated Grievance received regarding Patient 2 on 6/14/2021 and lacked documentation of letter regarding grievance and completion mailed to patient/complainant.

3. Interview with Personnel A1 on 8/10/2021 at approximately 1130 hours confirmed that the date listed on complaint/grievance log was the same date complaint/grievance received and discussed initially with complainant unless another date was documented and no final letter was routinely mailed to patient/complainant regarding grievance and completion.