Failure to Maintain Background Check Documentation for Interim DON
Penalty
Summary
The facility failed to maintain written evidence that a background check was completed for the Interim Director of Nursing (IDON) at the time of hire. Review of the IDON's personnel file showed no documentation of a completed background check, despite facility policy requiring such screening for all potential employees. The Administrator and Human Resources (HR) staff were unable to confirm when or if the background check was completed, and no copy was available in the employee file. The IDON reported having completed the background check, but was unable to provide documentation, and the facility later determined that a new background check would need to be obtained. Interviews with the Administrator and HR staff revealed that the oversight occurred during a transition in HR leadership, and the issue was only discovered several months after the IDON's hire. Although the facility verified the IDON's nursing license and checked the Nurse Aide Registry at the time of hire, the required background check documentation was missing. Facility policies reviewed indicated that background, reference, and credential checks must be conducted and documented for all personnel prior to employment.