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.

ADVOCATE LUTHERAN GENERAL HOSPITAL 1775 DEMPSTER ST PARK RIDGE, IL 60068 Sept. 11, 2018
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
Based on document review and interview, it was determined that the Hospital failed to ensure only one (1) Registered Nurse, directed the Nursing Services for all patients. This potentially affects an average of 570 patients on census, each day.

Findings include:

1. On 9/12/2018, the Hospital presented a Department of Nursing organization chart. The chart included a Vice President of Nursing Services for the adult patients (E#20) and a Vice President of Nursing Services for the children patients. These two Vice Presidents of Nursing Services report to the President of the Hospital. The staff who report to E#20 are: The Director of the Emergency Department, Director of Critical Care, Director of Behavioral Health, Director of Women's Health, Director of Med/Surg/Rehab Unit, Director of Staffing Effectiveness, Manager of Clinical Documentation, Director of Case Management and the Director of Professional Development.

2. On 9/12/18 at approximately 11:15 AM, the Vice President (E #20) of the adult patients was interviewed. E #20 stated, "We have one Hospital that includes an adult Hospital and pediatric Hospital. The two Hospitals are included under the same CMS (Center for Medicare and Medicaid Services) provider number."

3. The Credential File for the President Of the Hospital (E #22) was reviewed on 9/12/18 at approximately 12:45 PM. E #20's credential's include a Bachelor of Arts in Biopsychology and Cognitive Science with a Master of Public Health.

4. On 9/12/18 at approximately 1:15 PM, an interview was conducted with the Director of Performance Excellence (E #23). E #23 stated that she had been looking at the requirement and there should be one Director of Nursing. E#23 added, even though we give the titles of Vice President of Nursing Services, they are considered as Directors of Nursing in the eyes of CMS (Centers for Medicare and Medicaid Services).