HospitalInspections.org

Based on document review and interview, it was determined that, the Hospital failed to ensure the supervision and monitoring of nursing and patient care services between 4:00 PM - 8:00 PM, for seven (7) days. This potentially affects all patients and staff in the Hospital.

Findings include:

1. On 02/05/19 at approximately 9:00 AM, the Facility document titled, "Nursing Supervisor Monthly Schedule" dated 01/13/19 - 02/09/19 was reviewed. The document included, "Names of Supervisors, the dates, 01/13/19...02/09/19...shifts of the nursing supervisors for each day..." The document included no supervisors covering the Hospital between 4:00 PM - 8:00 PM on 01/14/19, 01/15/19, 01/18/19, 01/21/19, 01/25/19, 01/28/19, 02/01/19 (seven days) in the four week schedule.

2. The Hospital document titled, "Job-Description: Administrative Nurse Supervisor" dated (09/23/16) was reviewed. The document included, "As a registered professional nurse, under the direction of...is accountable for the administrative coordination of all patient care services division activities which take place during the assigned tour of duty in the Manager's and/or Director's absence...after business hours on all shifts during weekends and holidays, the Administrative Supervisor is responsible for overall supervision of the operating of the entire Hospital during the assigned shift..."

3. The Hospital document titled, "Job-Description: Chief Nursing Officer" dated (09/23/16) was reviewed. The document included, "Responsible for daily operations with focus on Patient Care Services and participates in the executive governing body of the Hospital and directing departmental activities...Plans, organizes, directs and evaluates activities of the various departments...coordinates all departmental activities to ensure quality care..."

4. On 02/06/19 at approximately 8:58 AM, an interview was conducted with the Nursing Supervisor (E #25). E #25 stated, "During the day until 4:00 PM we have unit managers covering the unit. The evening nursing supervisor starts at 6:00 PM or 8:00 PM or 12:00 Midnight, based on the availability. I worked last night from 12:00 AM until 8:00 AM. I do my rounds and definitely look into staffing and census for each unit...I am not sure if there are Nursing Supervisors covering the House all shifts..."

5. On 02/06/19 at approximately 11:55 AM, an interview was conducted with the Quality Coordinator (E #29). E #29 stated, "As, I am seeing the schedule, there is nobody covering the House during those dates (01/14/19, 01/15/19, 01/18/19, 01/21/19, 01/25/19, 01/28/19 and 02/01/19) between 4:00 PM - 8:00 PM..."

6. On 02/06/19 at approximately 12:45 PM, an interview was conducted with the Chief Nursing Officer (E #2). E #2 stated, "Yes, it was brought to my attention that, there is no nursing supervisors covering between 4:00 PM - 8:00 PM on all those dates on the schedule...I tell the charge nurses and nurse managers to cover the unit during that time..." Upon asking, then why do we need nursing supervisors from 8:00 PM - 8:00 AM, E #2 responded, "Oh, I see your point, there is no supervision for nursing services present in the building...there is no help for the nurses..."

7. On 02/06/19 at approximately 1:20 PM, an interview was conducted with the Director of Quality (E #1). E #1 stated, "I did not see this schedule until now, I do not know why there is holes in this schedule...there must be nursing supervision by leadership at all times..."

8. On 02/06/19 at approximately 1:45 PM, an interview was conducted with the Chief Operating Officer (E #3). E #3 stated, "No, this is not acceptable, I just came to aware [know] of this situation, I will make sure, this does not happen from moving today onwards. If there is no coverage, anything could happen, an adverse event...supervision is required on nursing areas."