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*TJCsvyrRN_Ostrowski_Kathleen Ostrowski RN, BSN, MPA, CNRN – HAP Nurse


Kathleen Ostrowski, RN, BSN, MPA, CNRN – HAP Nurse


Surveyor Program(s): Accreditation Manual for Hospitals

Surveyor Tenure: x 2005

Lives: Indiana

TJC Bio:

  • Assistant Vice President for Nursing and Service Line Manager for Neuroscience at the Methodist Hospitals in Merrillville and Gary Indiana.
  • Diploma in Nursing from South Chicago Hospital School of Nursing, a Bachelor of Science in Nursing from Lewis University, Lockport Illinois and a Master in Public Administration from Indiana University, NW
  • Background in Critical Care areas of Neuroscience, Cardiac and Trauma

Other Background:

  • xxxxx 

Comments & Recommendations


  • She admits not much psych background and she tends not to delve into psych issues. Rather focuses on medication management, med errors (may ask what is your most common med error), PI implications of data, contracts.  Very safety minded and very observant.  Wants to see pt ed documented in chart. Likes to teach.
  • Let her teach.  She sometimes allows org to pick patients so be prepared. Doesn’t like a large entourage so limit her escorts and use medically oriented staff
  • She like our honesty in reporting less than 100% compliance with NPSG 7c

  • xxxxx 

Relevant Survey History:

• Eastern Louisiana Mental Health System 06/06/08  • Choate Mental Health Center 12/15/16
• RST Forensic Treatment Center 1105



** Sample Survey Citations (Premier Level)**

[private Membership premier]


Sample Citations:


  • NPSG.2c/EP3: Timeframe for internal notifications not adequately defined.
  • PC.04.10/EP 2: Treatment plan inadequately reflecting medical care. /Indirect/ 
  • IC.02.10/EP 3: Mold problem in radiology dept room. /Indirect/ 
  • HR.01.20/EP 3: No PSV of beautician license. Barber with no license.


  • NPSG.01A: Observed in Tracer Activities:  while watching an RN pass out medications, that in three cases he identified the patients using a picture on the MAR. However he did not ask the patients their name or for any other second identifier. He admitted that since he knew the patients so well he felt he needn’t bother.
  • NPSG.03C: Observed in Individual Tracer:  When the night pharmacy was reviewed. The refrigerator contained several vials of insulin including Novulin N and R in like packaging. There was no indication these were segregated or labeled to reflect the high alert of a look alike and sound alike drug.
  • LD.03.70/EP1: Observed in Competency Review:  For the pharmacy delivery personnel there were no competency standards set or policy for provision of this procedure. The personnel records reviewed contained no evidence of supporting documentation for competence to handle prescription medications or class two drugs. Additionally, the personnel assigned to this task of picking up and delivering all medications between the Pharmacy and Inpatient Care Units were lower status employees, not licensed nor certified, and had not participated in any medication programs. Finally, there were no criminal background checks found within these records.
  • PC.08.10/EP3: Observed in Individual Tracer:  The same patient was noted by a different RN to have pain of 7, given the analgesic which was noted an hour later to be “effective”. There was no further pain assessment on the chart despite the fact that the underlying cause of the tooth pain had not yet been treated. There is no hospital policy to guide RN’s as to how often a patient with a score of 7 should be reassessed for pain.





You may provide surveyor feedback by clicking on the ‘Comments’ link above (2nd line, top left) and/or via the New Post Survey Questionnaire (PSQ).

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