HospitalInspections.org

Based on record review of the facility organizational chart, personnel file review, nursing job description and interview with the Chief Nursing Officer (CNO), the facility failed to ensure all nurses employed by the hospital reported to a nurse manager who reported to the CNO. Findings include:

A. Personnel file review of Licensed Practical Nurse (LPN)-F on 12/16/13 revealed the LPN worked in the Rheumatology office. Review of the last performance appraisal completed 8/21/13 found it was done and signed by the Office Coordinator who was not a nurse. Staff interview with the Human Resources Manager on 12/16/13 at 3:30 PM revealed the Rheumatology 3 LPNs and 1 RN (Registered Nurse) are employed by the hospital but the Rheumatology office is a contracted service. Review of the hospital Organizational chart finds Rheumatology staff report to the Office Coordinator and up to the Chief Financial Officer (CFO) and not to or through nursing. Review of the undated job description identifies the Clinic RN reports to the Rheumatology Consultants Office Coordinator.

B. Interview with the CNO on 12/18/13 at 1:15 PM confirmed that the following areas have nursing staff that do not report to a nurse manager or to her but are hospital employees. Record review of job descriptions also confirmed the non-nursing manager for each service.
- Rheumatology Clinic has 1 RN and 3 LPNs report to Clinic Manager;
- Clinical Nurse Educator RN reports to Human Resource Manager;
- Education Coordinator RN reports to Human Resource Manager;
- Employee Health and Wellness RN reports to Human Resource Manager;
- Infusion Center has 3 RNs that report to the Pharmacy Manager;
- 2 RN Auditors report to Patient Financial Services;
- 3 RN Auditors report to Quality and Accreditation;
- The Systems Manager Information Technology department has 2 RNs who report to the Chief Information Officer.