HospitalInspections.org

Based on a review of documentation, the governing body failed to be responsible for all services furnished in the hospital.

Findings were:

Facility policy #NA-1005 titled "Nursing Staffing Advisory Committee" states, in part,
? POLICY: The Hospital will have a Staffing Advisory Committee that complies with the provisions of the Health and Safety Code (HSC) ?161.031-161.033.

(F) The hospital shall establish a nurse staffing committee as a standing committee of the hospital. The committee shall be established in accordance with Health and Safety Code (HSC), ??161.031 - 161.033, to be responsible for soliciting and receiving input from nurses on the development, ongoing monitoring, and evaluation of the staffing plan. As provided by HSC, ?161.032, the hospital's records and review relating to evaluation of these outcomes and indicators are confidential and not subject to disclosure under Government Code, Chapter 552 and not subject to disclosure, discovery, subpoena or other means of legal compulsion for their release. As used in this subsection, "committee" or "staffing committee" means a nurse staffing committee established under this subparagraph.
(i) The committee shall be composed of:
(I) at least 60% registered nurses who are involved in direct patient care at least 50% of their work time and selected by their peers who provide direct care during at least 50% of their work time;
(II) at least one representative from either infection control, quality assessment and performance improvement or risk management;
(III) members who are representative of the types of nursing services provided at the hospital; and
(IV) the chief nursing officer of the hospital who is a voting member.
(ii) Participation on the committee by a hospital employee as a committee member shall be part of the employee's work time and the hospital shall compensate that member for that time accordingly. The hospital shall relieve the committee member of other work duties during committee meetings.
(iii) The committee shall meet at least quarterly.
(iv) The responsibilities of the committee shall be to:
(I) develop and recommend to the hospital's governing body a nurse staffing plan that meets the requirements of subparagraph (G) of this paragraph;
(II) review, assess and respond to staffing concerns expressed to the committee;
(III) identify the nurse-sensitive outcome measures the committee will use to evaluate the effectiveness of the official nurse services staffing plan;
(IV) evaluate, at least semiannually, the effectiveness of the official nurse services staffing plan and variations between the plan and the actual staffing; and
(V) submit to the hospital's governing body, at least semiannually, a report on nurse staffing and patient care outcomes, including the committee's evaluation of the effectiveness of the official nurse services staffing plan and aggregate variations between the staffing plan and actual staffing.
A review of facility documentation revealed that no valid Nurse Staffing Advisory Committee meetings had been held in 2012 or thus far for 2013.

The above was confirmed in a meeting with the Director of Human Resources, the Quality Coordinator, the Director of Operations and other administrative staff on the afternoon of 7-17-13 in the facility conference room.