"The HD unit had multiple problems that required improvement. The unit was lacking a strong leadership presence in the nurse manager and charge nurse roles. It was difficult to differentiate between the role of the RNs and the LPNs. There was no defined responsibility for the charge nurse and no policy for reporting events to the charge nurse or a physician."Ultimately the Inspector General's investigation yielded six recommendations for the HD unit that include explicit delineation of duties for RNs and LPNs, that a process for determining the competency of RNs and LPNs be developed and put into practice, and that John Cochran's human resources department evaluate the "accuracy of job descriptions, the use of leave and potential scheduling issues."
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