HospitalInspections.org

Based on document review and interview, it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.23, Nursing Services.

Findings include:

1. The hospital failed to ensure that the designated Chief Nursing Officer/CNO (E #20) responsible for the practice of nursing services in the hospital, was qualified, as required. See A-386.

Based on document review and interview, it was determined that the hospital failed to ensure that the designated Chief Nursing Officer/CNO (E #20) responsible for the practice of nursing services in the hospital, was qualified, as required.

1. On 7/16/2024, the hospital's "Governing Body Meeting Minutes" (3/15/2024) was reviewed and indicated, "(Name of the Hospital's CEO/E #17) reported that (E #21/Chief Operating Officer) has resigned (as the Chief Nursing Officer) effective (March 25, 2024)...a new CNO should be announced in the next 2 weeks..."

2. On 7/16/2024, the personnel file for E #20 (Chief Nursing Officer) was reviewed. The file indicated the following:
- A letter from E #17, dated April 23, 2024, that indicated, "To (E #20)... Your position will be Chief Nursing Officer (Full-Time...) reporting to (E #17)... "
- A job description titled, "Chief Nursing Officer" indicated, "... The Chief Nursing Officer is responsible for the practice of Nursing by ensuring consistence in the standard of practice across clinical settings... The CNO supports and facilitates an interdisciplinary team approach to the delivery of care... Minimum Qualifications... Certification/Licensure: License Registered Nurse in Illinois..."
- E #20 lacked an Illinois license as a Registered Nurse.

3. On 7/16/2024 at approximately 12:00 PM, an interview was conducted with E #20 (Chief Nursing Officer). E #20 stated that E #20 does not have a current Illinois license.