HospitalInspections.org

Based on document review and interview, for 4 of 5 patient's (Pt. #6-Pt. #9) clinical records reviewed for provision of care provided by a Nurse Extern (E #1), the hospital failed to ensure that the registered nurse provided supervision of care.

Findings include:

1. On 9/30/2025, the hospital's 'Nurse Extern Skills List" (revised 7/26/2023) was reviewed and included, " ...Scope of RN (registered nurse) and Unlicensed Assistive Personnel (e.g. nurse extern) ...The RN is ultimately responsible for the nursing process including assessment, care planning, implementation, and evaluation ...Physical Assessment: RN to cosign assessments ...Revise Plan of Care (RN to review Care Plan every shift) ...May perform with Collaboration/Direct Observation: ...administer medications ...".

2. On 12/02/2025, the clinical record of Pt. #6 was reviewed. Pt. #6 was admitted on 08/09/2025 with chief complaint of pregnant not yet delivered in third trimester. The record lacked documentation of supervision by a registered nurse for patient care provided by E #1 on 8/12/2025.

3. On 12/02/2025, the clinical record of Pt. #7 was reviewed. Pt. #7 was admitted on 9/22/2025, with a chief complaint of pregnant not yet delivered in third trimester. The record lacked documentation of supervision by a registered nurse for patient care provided by E #1 on 9/22/2025.

4. On 12/03/2025, the clinical record of Pt. #8 was reviewed. Pt. #8 was admitted on 08/25/2025, with a chief complaint of pregnant not yet delivered in third trimester. The record lacked documentation of supervision by a registered nurse for patient care provided by E #1 on 8/28/2025.

5. On 12/03/2025, the clinical record of Pt. #9 was reviewed. Pt. #9 was admitted on 09/22/2025, with a chief complaint of pregnant with pelvic pain. The record lacked documentation of supervision by a registered nurse for patient care provided by E #1 on 9/22/2025.

6. On 12/03/2025 at approximately 10:31 AM, an interview with the Clinical Manager of Operations (E #6) was conducted. E #6 stated that a registered nurse is paired with a nurse extern, to supervise all aspects of patient care provided. E #6 stated that the registered nurse is to have oversight of all patient care documentation and must co-sign any and all documentation that a nurse extern documents. E #6 stated, after review of patient's (Pt. #5-Pt. #9) clinical records, that the records lacked the co-signature of a registered nurse, as required. E #6 stated that a registered nurse's oversight of the nurse extern is to ensure patient and staff safety and there is a hospital policy and guidelines in place to ensure proper oversight is met.