HospitalInspections.org

Based on records reviewed and interview the Hospital failed to ensure that all nursing personnel was duly licensed.

The Surveyor toured the Satellite Unit of Hospital A and interviewed the Senior Director of Nurses at 7:30 A.M. on 1/28/19. The Satellite Unit of Hospital A is located on a floor within Hospital B also referred to as a Hospital within a Hospital. The Senior Director of Nurses said there were numerous contracted shared services with Hospital B and provided the Surveyor with a contract between Hospital A and Hospital B. The Senior Director of Nurses said that when a patient from Hospital A required emergency services like a Rapid Response Team (a group of clinicians who provide immediate response at the bedside of a patient whose condition is deteriorating) or a Code Blue (Cardiac Arrest) the response was furnished by nurses who were working in the Intensive Care Unit of Hospital B, the host Hospital. The Senior Director of Nurses said these nurses were not a part of her staff and she would not know about the status of their licenses or competencies.

The Surveyor reviewed Patient #5's medical record at 8:30 A.M. on 1/28/19. The medical record indicated a Rapid Response was called on 11/3/18 and signed by an ICU RN.