HospitalInspections.org

Based on a review of facility documentation and staff interview, the facility failed to ensure nurse staffing and all services provided were furnished according to state regulations.

Findings were:

A review of facility documentation revealed no minutes for a nurse staffing advisory committee as required by the Texas Health and Safety Code §§161.031-161.033, which was responsible for soliciting and receiving input from nurses on the development, ongoing monitoring, and evaluation of the hospital's nurse staffing plan.

In an interview with the Director of Nurses on the morning of 3/1/16 in the hospital meeting room, the minutes of the nurse staffing advisory committee were requested. She stated, "We don't have a committee like that. I was looking at the regs last night and I realized this was going to be a problem."

Facility policy entitled Nurse Staffing Plan, effective date 9/1/15, included the following:
"3. Ballinger Memorial Hospital has established a Nurse Staffing Committee ("The Committee") as a standing committee of the hospital.
a. The Committee is responsible for soliciting and receiving input from nurses on the development, ongoing monitoring, and evaluation of the staffing plan..."

In addition, the hospital failed to develop and implement policies and procedures to ensure that a sexual assault survivor presenting at the hospital was either transferred to another facility or provided care at the hospital according to state regulatory requirements.

Facility emergency room policy entitled Policy Regarding Examination of Alleged Rape Victims, no effective date, included the following:
"It is our policy to transfer to Shannon ER any alleged rape victim that presents to the Emergency Room. However, the decision to transfer or to examine the alleged victim will be made by our Physician on duty in the ER."

In an interview with the Director of Nursing on the morning of 3/1/16 in the hospital meeting room, she stated, "I can tell you we'd transfer any patient that would show up with this. But our policy says it's up to the physician." Upon discussion of whether the facility met state regulatory requirements to provide services to survivors of sexual assault, for example, having submitted a plan to the Texas Department of State Health Services detailing its provision of such services, she stated the hospital did not meet all the state regulatory requirements.

The above findings were again confirmed in an interview with the chief executive officer and other administrative staff on the afternoon of 3/1/16 in the hospital meeting room.