The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based upon record review and interviews, the hospital failed to ensure the nursing services was organized to identify authority and delineation of responsibilities related to the provision of direct patient care provided by Registered Nurses who were not employed by the hospital. This was evidenced by allowing Registered Nurses from the Medical School to provide direct patient care to patients in the outpatient Ambulatory Care Clinic for 1 of 6 (Patient #1) outpatient records reviewed. Findings:

Review of patient #1's outpatient medical record revealed on 07/12/16, this 8 year old male presented to the pediatric endocrine clinic accompanied by his mother for a growth hormone stimulation test which required blood samples to be drawn. On 07/12/16 at 10:16 a.m. S6RN documented "IV access attempted unsuccessfully. Mother requested CRN (Certified Registered Nurse Anesthetist) to try IV access." "1017 (10:17 a.m.) Waiting on mom and patient to return to testing infusion room. (S12Physician) notified of IV difficulty." "1440 (2:40 p.m.) Test completed. IV lock discontinued. Patient able to tolerate oral intake and able to ambulate without difficulty."

Interview with S2RN/CNO on 08/22/16 at 2:30 p.m. revealed when asked who S6RN was employed by, S2RN/CNO replied S6RN was employed by the local Medical School and was S12Physician's nurse. When asked if there was a personnel file, a contract or if S6RN had gone through a credentialing process, S2RN/CNO replied "no" and added the Medical School had the personnel file.

Interview with S6RN on 08/22/16 at 3:30 p.m. revealed she was an employee of the Medical School and worked for S12Physician. S6RN was asked if she provided direct patient care to the patients in the ACC (Ambulatory Care Clinics) and responded she would start Intravenous Infusions when needed.

Review of the organizational chart for the Ambulatory Care Clinic, an outpatient department of the hospital, revealed each department was assigned a Nursing Supervisor and Registered Nurses; however, the organizational chart did not include and/or identify the Registered Nurses from the Medical School who accompany the physicians and provided direct patient care to the clinic's patients.

Review of the list of medical school Registered Nurses dated August 23, 2016 revealed S6RN was listed as an employees of the Medical School. There failed to be documentation of the administrative authority and delineation of responsibilities for the Registered Nurses who were providing direct patient care but were not employed by the hospital.