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DOCTORS MEMORIAL HOSPITAL INC 333 N BYRON BUTLER PKWY PERRY, FL 32348 July 8, 2013
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
Based on interviews, personnel file reviews and review of facility's organizational chart, the provider failed to ensure the hospital-wide nursing service was provided under the direction of a Registered Nurse.

Findings:

Review of facility's organization chart with most recent revision date of 5/1/13 documented the following departments reporting directly to the Chief Clinical Officer: Materials Management, Home Health, Pharmacist, Registered Dietician, Dietary, Education/Infection Control/Employee Health, Environmental Services, Surgical Services, emergency room , and Intensive Care Unit/Medical/Surgical Units.

An interview was conducted with the Chief Clinical Officer (CCO) on 7/8/13 at approximately 12:15pm. The CCO stated the previous Chief Nursing Officer left to take a position elsewhere, stated she came in February 2013 to fill the position; and confirmed she is a respiratory therapist and not a registered nurse. The CCO stated the facility does not have a Chief Nursing Officer, but instead there are three Nursing Directors at the hospital that includes a Registered Nurse (RN) Intensive Care Unit/Medical Surgery Director; an emergency room RN Director; and a RN Surgical Services Director. The CCO stated the three Registered Nurses provide the direction of nursing services and report directly to her.

The CCO stated she is a Registered Respiratory Therapist, was previous director of Respiratory at Tallahassee Memorial Hospital (TMH) prior to accepting this position, and provided oversight of departments outside of respiratory while in that position. The CCO states she and the Executive Director are employees of Tallahassee Memorial Healthcare. The CCO confirmed she is not a Registered Nurse.

A telephone interview was conducted with the facility's Chief Executive Officer (CEO) on 7/8/13 at approximately 1:35pm. When asked who is responsible for direction of nursing services, the CEO stated the ICU/Medical/Surgical Registered Nurse is over scheduling, over quality, and has matrix with peers with emergency room and Surgery. The CEO stated the ICU/Med/Surg manager works closely with Surgical Services Director and emergency room Director. The CEO stated approval for this type of model, using a respiratory therapist in the director level position, was obtained from the Agency for Healthcare although was not able to provide documentation of such during survey visit.

The CEO further stated that nursing gathers Quality Assurance Performance Improvement activities and provides directly to the facility's Risk Manager (RM). The CEO stated the RM shares the information with her and is presented to appropriate medical staff committees for which the Chief Clinical Officer is present.

An interview was conducted with the ICU/Med/Surg nurse manager on 7/8/13 at 2:00pm. The nurse stated she reports directly to the Chief Clinical Officer. Review of job description titled "Medical Surgical Registered Nurse Manager" position, updated 6/13/13, was conducted. The job summary documented the RN Manager is directly responsible for the planning, coordination and monitoring of care and patient outcome on an assigned group of acutely ill patients. The supervisor is documented as Chief Clinical Officer.

An interview was conducted with the emergency room nurse manager on 7/8/13 at 2:10pm. When asked who she reports to, she stated they now have a Chief Clinical Officer to whom she directly reports. Review of job description titled "Emergency Department Registered Nurse Manager" position, updated 6/13/13, was conducted. The job summary documents the RN Manager has 24-hour responsibility and authority within guidelines as established by Nursing service. This person is accountable for decision making relative to the management of clinical and management setting. The supervisor is documented as Chief Clinical Officer.

Review of job description titled "Surgical Services Manager" documented the Operating Room (OR) Supervisor/Director being accountable for decision making relative to the management of the Surgical Department, including Operating Room, Post Anesthesia Care Unit, Endoscopy and Outpatient Surgical Area. Documents the OR Director is under the supervision of the Chief Nursing Officer. Job description documents supervision by Chief Clinical Officer.

Review of Chief Clinical Officer job description documented supervision of nursing, cardio-pulmonary, case management and dietary services. Position documented "reporting to the Chief Executive Officer of Doctor 'Memorial Hospital, the CCO is responsible for clinical practice in Nursing, Cardio-Pulmonary, Case Management, Dietary Services, across all clinical settings, supporting and facility an interdisciplinary approach to the delivery of care. The license criteria is documented as "Florida Registered Nurse, Pharmacist or Respiratory Therapist."