HospitalInspections.org

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Based on interview and document review, the Governing Body failed to ensure that the appointed Chief Executive Officer (CEO) was responsible for managing the entire hospital to include offsite clinics under the hospital license.

Failure to appoint a Chief Executive Officer to manage the entire hospital risks ineffective oversight and inadequate management of the hospital by one responsible individual.

Findings included:

1. On 04/05/24 at 10:45 AM, Surveyor #5 and Surveyor #9, the Chief Operating Officer (Staff #904), Chief Nursing Officer designee (Staff #907), and Chief Executive Officer (Staff #908) reviewed an organizational chart titled, "PHMG Northwest Network," updated on 01/15/24, which showed off site services provided by the hospital.

2. At the time of the review, Staff #908 verified that the services provided at the offsite hospital facilities to include: PeaceHealth Senior Health at Medical Office Plaza, PeaceHealth Orthopedics, Sports Medicine and Trauma Surgery, and PeaceHealth Neurology at Cascade Brain and Spine Center, report directly to the Vice President PeaceHealth Medical Group. Staff #908 stated that himself, the Vice President of Operations, and the Chief Medical Officer of the PeaceHealth Medical Group have a "collegial" relationship. Staff #908 stated that they meet regularly but there was no direct reporting relationship to the hospital Chief Executive Officer.
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Based on observation, interview, and document review, the hospital failed to ensure the Hospital operated under one unified nursing service under the direction of one Registered Nurse who was responsible for the quality of care provided to hospital patients by hospital and non-hospital nursing staff.

Failure to ensure that Nursing Services are provided under the direction of one hospital-wide nursing service under the direction of one Registered Nurse accountable for the quality of nursing care provided to its patient's places patients at risk for inconsistent or inadequate care, adverse outcomes, and death.

Findings included:

1. The hospital failed to ensure that PeaceHealth St Joseph Medical Center operated with one hospital-wide Nursing Service, and failed to ensure that a single nursing service was under the direction of one Registered Nurse (RN) responsible for the operation of the services and the quality of the patient care provided by nursing services.

Cross Reference: A0386
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Based on interview and document review, the hospital failed to ensure that PeaceHealth St Joseph Medical Center hospital operated with one hospital-wide Nursing Service, and failed to ensure that a single nursing service was under the direction of one Registered Nurse (RN) responsible for the operation of the service and the quality of the patient care provided by nursing services.

Failure to ensure that Nursing Services are provided under the direction of one hospital-wide nursing service under the direction of one Registered Nurse places patients at risk for suboptimal care, adverse outcomes, and death.

Findings included:

1. Document review of the Chief Nursing Officer (CNO) Northwest Job Description showed that the CNO was accountable for the overall clinical outcomes, operations, nursing practice, and financial performance for the assigned areas.

Document review of the hospital's organizational chart for nursing titled, "PeaceHealth St Joseph Medical Center," dated March 2024, showed the following:

a. The Medical/Surgical units, float pool, Infusion Services, House Managers, Intensive Care Unit, Progressive Care Unit, Respiratory therapy, Care management, Behavioral Health, Childbirth Center, Pediatrics, Emergency department and Pharmacy were assigned and directly reported to the Chief Nursing Officer.

b. Perioperative Services including Surgery, Same Day Surgery, Short Stay Unit, Post Anesthesia Unit, Endoscopy, Sterile Processing Department, and Imaging were assigned and reported directly to the Chief Operating Officer.

c. The Wound Healing Center and Cardiovascular Center were assigned and reported directly to the Executive Director of Cardiovascular Services who reported to the Chief Operating Officer.

d. The Cancer Center reported directly to the Vice President of Operations of the PeaceHealth Medical Group.

e. The organizational chart showed a dotted line or matrixed reporting (reporting to more than one leader) to the Chief Nursing Officer for Perioperative Services, Nurse Manager Wound Healing Center, Nurse Manager Cardiovascular Services, and Nurse Manager Oncology Services.

Document review of the Director of Perioperative Services (Staff #903) job evaluation titled, "Performance Review Period July 1, 2022-June 30, 2023," showed that the review was completed and signed by this person's manager identified in the document as the Chief Operating Officer (Staff #904).

Investigator #9 found no evidence the CNO was responsible for the operation of the service Perioperative Services or evaluated the performance of the Perioperative Nursing Director (Staff #903) as part of his/her responsibility for a single nursing service under the direction of one Registered Nurse.

Document review of the Job Description for the job title, Executive Director Cardiovascular Services, showed that an essential function of the position is supervising management, technical, nursing, and administrative staff.

Document review of the Nurse Manager Wound Healing Center (Staff #905) job evaluation titled, "Performance Review Period July 1, 2022-June 30, 2023," showed that the review was completed and signed by this person's manager identified in the document as the Executive Director Cardiovascular Services (Staff #906).

Investigator #9 found no evidence the CNO was responsible for the operation of the Wound Healing Center or evaluated the performance of the Nurse Manager (Staff #905) as part of his/her responsibility for a single nursing service under the direction of one Registered Nurse.

2. On 04/04//24 at 3:00 PM, Investigator #5 and Investigator #9 and Chief Operating Officer (Staff #904), Chief Nursing Officer designee (Staff #907), and Chief Executive Officer (Staff #908) reviewed the hospital's organizational chart and oversight and responsibility for nursing services provided to patients at PeaceHealth St Joseph Medical Center.

3. At the time of the review, Staff #904 verified that the organizational chart showed that Perioperative Services including Surgery, Same Day Care, Short Stay Unit, Post Anesthesia Unit, Endoscopy, Cardiovascular Center, and Wound Care reported up through him. He stated that the CNO provided oversight and direction of staffing and other nursing practices although the staff directly reported to them. Staff #904 verified that they had completed the evaluation of the Director of Nursing for Perioperative Services and the Executive Director of Cardiovascular Services.

4. At the time of the review, Staff #906 verified that they had completed the evaluation of the Nurse Manager of the Wound Healing Center and there was no input from the CNO into that evaluation.
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