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ADVOCATE LUTHERAN GENERAL HOSPITAL 1775 DEMPSTER ST PARK RIDGE, IL 60068 Aug. 19, 2021
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined that for 1 of 3 (Pt. #1's) clinical records reviewed regarding coordination of care, the Hospital failed to ensure that the Registered Nurse supervised and evaluated the care of each patient by failing to notify a change of the patient's discharge need to the physician.

Findings include:

1. On 8/17/2021, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]#1 was schedule to have an upgrade to his pacemaker device on to CRT-D (cardiac resynchronization therapy defibrillator). The clinical record included:

- A physical therapy (PT) evaluation dated 12/11/2019 included, " ...Mental Status: Impaired ... Assessment/Plan ... (Pt. #1) Is not at his baseline ...recommend 24-hour unskilled assistance and non-daily skilled therapy. Message left for CM (Case Management) ... End of Session Patient Status ... Hand-off To ... RN (registered nurse) ..."

The clinical record lacked documentation the physician was notified of the change in the patient's discharge needs. Pt. #1 was discharged home with no referrals or arrangement made for home aid and physical therapy.

2. On 8/20/2021, the Hospital's Job Description for Registered Nurse (effective 1/2021) was reviewed and included, " ... Responsible for providing and coordinating comprehensive patient care through the nursing process to deliver safe, therapeutic care in accordance with established standards, policies and procedures ... I. Accountabilities and Job Activities ... D. Actively coordinates the discharge plan utilizing an interdisciplinary approach ..."

3. On 8/20/2021 at approximately 12:00 PM, findings were discussed with E #13 (Clinical Manager). E #13 stated that the nurse should have notified the physician regarding the physical therapy's recommendation and change in Pt. #1's discharge needs. E #13 could not provide documentation that the physician was notified.

4. On 8/20/2021 at approximately 1:30 PM, findings were discussed with E #22 (Case Manager). E #22 stated that the physical therapy evaluation on 12/11/2019 indicated that Pt. #1 needed home aid and physical therapy referral and arrangement. E #22 stated that the clinical record did not indicate that a home physical therapy and aid referral and arrangement was made for Pt #1.