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SINAI-GRACE HOSPITAL
NURSING SERVICES
Tag No.: A0385
Based on interview and record review, the facility failed to ensure the Chief Nursing Officer held a current state license as a registered nurse resulting in the potential for less than optimal outcomes for all patients.
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(A-0386) Based upon document review and interview the facility failed to ensure the Chief Nursing Officer for the facility held a current state license resulting in the potential for poor patient outcomes for all patients.
ORGANIZATION OF NURSING SERVICES
Tag No.: A0386
Based upon document review and interview the facility failed to ensure the Chief Nursing Officer for the facility held a current state license resulting in the potential for less than optimal outcomes for all patients. Findings include:
On 8/4/2022 at 0921 during the document review of the Chief Nursing Officer's (staff B) employee file it was revealed staff B was not licensed in the State of Michigan as a registered nurse.
On 8/4/2022 at 0940 an interview occurred with staff B, the Chief Nursing Officer and the Director of Quality (staff D). Staff B was queried if she was licensed in the State of Michigan as a registered nurse. Staff B stated, "No...I have contacted the State of California and have not been successful in getting them to send my endorsement to LARA (Licensing and Regulatory Affairs)...I sent a check to them in April and they told me it would be four to six weeks." Staff B was asked if she was licensed in California. Staff B stated, "No that is where I took my boards...I am licensed in North Carolina." Staff B was asked to produce documentation that she was licensed in North Carolina. Staff D stated during the interview, "Well (staff B) works under the licensure of our Corporate Chief Nursing Officer...and she just left the federal system where it doesn't matter where the license is in the federal system." Staff B produced documentation that she was licensed in the state of North Carolina with a license expiration date of 8/31/2022. Staff B stated she did not intend to renew her license in North Carolina.
On 8/4/2022 at 1100 a document review of "Position Specification" for the "Chief Nursing Officer" (undated) was reviewed. According to the document, under the subtitle "Education/Certifications", it states "Active and current registered nurse license in the state of residence/practice is required."