HospitalInspections.org

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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 the 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 responsible for the operation of the services and the quality of the patient care provided by nursing services.

Cross Reference: A0386

2. Based on interview and document review, the hospital failed to ensure the Director of Nursing Operations or designated qualified hospital registered nurse conducted clinical evaluation activities of all shared services nursing personnel who provided patient care.

Cross Reference: A0398
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Based on interview and document review, the hospital failed to ensure that St Clare 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 responsible for the operation of the service and the quality of patient care provided by nursing services.

Failure to ensure that Nursing Services are provided under the direction of one 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 hospital's organizational chart titled, "St. Clare Hospital," dated 2023, showed the following:

a. The Med Tele Units, Progressive Care Unit, Intensive Care Unit, Ortho/Surgical, Outpatient Oncology, and Emergency Services reported directly to the Director of Nursing Operations.

b. Perioperative Services including Surgery Services and Sterile Processing, Recovery Services, and Interventional Radiology Nursing Services report directly to the Chief Operating Officer.

c. The Organization chart stated that positions with a solid line indicated a direct report. The position of Perioperative Services Director showed a solid line to the Chief Operating Officer.

Document review of the Job Description for the job title, "Director Perioperative Services," states that the position reports to, "Depends on assigned facility." Under the section titled, "Job Summary," the document stated, "working closely with the Medical Director and other hospital department managers to integrate/coordinate/evaluate all phases of patient care, and "providing input to the hospital President for development, implementation, monitoring, and other operational issues."

Investigator #9 found no evidence Perioperative Services or the Perioperative Services Director, Surgery Services and Sterile Processing, Recovery Services, or Interventional Radiology Nursing Services was under the direction of the Director of Nursing Operations.

2. On 03/21/24 at 4:05 PM, Investigator #9 and the Director of Nursing Operations (Staff #911) discussed the hospital's organizational chart and oversight of nursing services. Staff #911 verified that all Perioperative Services reported to the Chief Operating Officer. Staff #911 verified that they were the nurse who had oversight for the rest of the nursing services within the hospital. Staff #911 stated that that the Director of Nursing Operations and the Chief Operating Officer collaborate, meet monthly, and provide dual oversight. Staff #911 was unable to provide any documentation of this collaboration as there were no meeting minutes.
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Based on interview and document review, the hospital failed to ensure the Director of Nursing Operations or designated qualified hospital registered nurse conducted clinical evaluation activities of all shared services nursing personnel who provided patient care.

Failure to evaluate the nursing care provided by non-hospital personnel by a qualified hospital registered nurse risks patients receiving inconsistent or inadequate care.

Findings include:

1. Document review of the hospital's organizational chart titled, "St. Clare Hospital," dated 2023, showed that Wound Care Services and Gastroenterology Services are not listed on the organizational chart, and both provide nursing services to patients receiving care at St Clare Hospital through a shared service agreement.

Document review of the hospital agreement titled, "Reciprocal Shared Services and Employee Lease Agreement by and Among Franciscan Health System and its Affiliated Entities, Hospitals, and other Operations", and "Statement of Work" (SOW), no policy number, no date, showed the following:

a. The "Lessor" will provide technical or professional personnel ("leased employee") to another (the "Lessee") to perform services on behalf of the other.

b. The Lessee shall exercise exclusive oversight, direction, and clinical supervision of the leased employee.

c. The Lessee shall evaluate the leased employee's job performance on a regular basis and provide such an evaluation to the Lessor.

2. On 03/21/24 at 4:05 PM, Investigator #9 and the Director of Nursing Operations (Staff #911) discussed the hospital's organizational chart, oversight of nursing services, and evaluation of shared services. Staff #911 verified that they do not evaluate the performance of the nursing staff within the Wound Care team or Gastroenterology team that provide nursing services at the hospital. Staff #911 stated there is a manager for each of those teams and the evaluation is completed by them.
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