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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.11 Compliance with Federal, State and Local Laws was out of compliance.

A-0022 The hospital must be -- Approved as meeting standards for licensing established by the agency of the State or locality responsible for licensing hospitals. Based on interviews, and document reviews the facility failed to establish a nurse staffing committee and a master nurse staffing plan. Specifically, the facility failed to meet the requirements of CCR 1011-1 Chapter 4.14.6 for the establishment of a nurse staffing committee and Chapter 4.14.7. the development of a master nurse staffing plan.

Based on interviews, and document reviews the facility failed to establish a nurse staffing committee and a master nurse staffing plan. Specifically, the facility failed to meet the requirements of CCR 1011-1 Chapter 4.14.6 for the establishment of a nurse staffing committee and Chapter 4.14.7. the development of a master nurse staffing plan.

Findings include:

Facility policy:

The Master Nurse Staffing Plan and Nurse Staffing Committee policy read, a Nurse Staffing Committee (NSC) is responsible for developing a master nurse staffing plan (NSP). The NSC will: have at least 60 percent participation by clinical staff nurses, in addition to auxiliary personnel and nurse management. The NSC will submit the master NSP to the hospital's Chief Nursing Officer (CNO) and the hospital's Governing Body (GB) for approval. The NSP will be made available and reviewed with each individual member of the nursing staff annually. The hospital will evaluate the master NSP and prepare a report for internal review by the NSC on a quarterly basis.

The NSC will annually develop and oversee the master NSP. The master NSP includes guidance and a process for reducing nurse-to-patient assignments which will align with the patient care demand based on patient acuity. The master NSP is voted on and must be approved by at least 60 percent of the NSC.

Facility meeting minutes:

The Nurse Executive Committee (NEC) meeting minutes, volume 6, issue 2. Information for the staff section, read, the Master Nurse Staffing Grid was approved with the current staffing numbers. The Master Staffing Grid was approved by the NSC with no opposition.

The Nurse Staffing and Oversight Committee meeting minutes dated 6/23/22 read, the Master Nurse Staffing Grid represents appropriate staffing for the nursing department on each unit.

Facility resource:

The Master Nurse Staffing Grid, dated 6/27/22 listed the maximum patient capacity available on each patient unit, the staff-to-patient ratio for the patient unit, the nurse-to-patient ratio for the patient unit, and the acuity level assigned to the patients on the unit.

1. The facility failed to ensure the NSC was composed of at least 60 percent or greater clinical staff nurses.

a. Document review of the Nurse Staffing Oversight Committee meeting minutes held on 6/23/22 and 8/19/22 revealed the NSC was not composed of 60 percent or greater clinical staff nurses.

i. Review of the NSC member attendance on 6/23/22 revealed 23 staff members were present at the meeting. Of the 23 staff members present, only one staff member was a clinical staff nurse.

ii. The member attendance was reviewed for the Nurse Staffing Oversight Committee meeting held on 8/19/22 and revealed of the 11 staff members present at the meeting, three of the staff members were clinical staff nurses.

b. On 12/28/22 at 11:40 a.m., an interview was conducted with CNO #1. CNO #1 reviewed the Nurse Staffing Oversight Committee meeting minutes provided by the facility for 6/23/22 and 8/19/22. CNO #1 stated on 6/23/22 one clinical staff nurse was present at the meeting. Additionally, CNO #1 stated the remaining 22 staff members present at the Nurse Staffing Oversight Committee meeting consisted of 21 supervisory staff members and one clinical care aid (CCA).

The Nurse Staffing Oversight Committee meeting minutes for the meeting held on 8/19/22 were reviewed by CNO #1. CNO #1 stated a total of 11 staff members were present at the NSC meeting on 8/19/22 and three of the 11 staff members in attendance were clinical staff nurses. CNO #1 stated Nurse Staffing Oversight Committee meetings did not have an adequate number of clinical staff nurses present. CNO #1 stated 60 percent of the staff members who attended the Nurse Staffing Oversight Committee meetings on 6/23/22 and 8/19/22 were nursing supervisors, not clinical staff nurses. Furthermore, CNO #1 stated supervisory staff and CCAs were not considered clinical staff nurses at the facility.

The composition of the staff members in attendance at the NSC meetings on 6/23/22 and 8/19/22 were in contrast to the Master Nurse Staffing Plan and Nurse Staffing Committee policy which stated, the NSC will be composed of at least 60 percent clinical staff nurses in addition to being composed of ancillary staff and members of nurse management.

c. On 12/29/22 at 4:19 p.m., interviews were conducted with CNO #1, the chief executive officer (CEO) #2 and the chief quality officer (CQO) #3.

i. During the interview, CQO #3 stated a NSC had been established. CQO #3 stated the NSC had to consist of 60 percent clinic staff nurses. CQO #3 then stated the NSC members present at the NSC meetings held on 6/23/22 and 8/19/22 were not composed of 60 percent clinical staff nurses.

iii. During the interview, CEO #2 stated the facility had attempted to establish a NSC, however, the facility was unable to construct a committee composed of 60 percent clinical staff nurses. CEO #3 stated the committee established by the facility could not be considered as a NSC in accordance with the Chapter 4 regulations because it was not composed of 60 percent clinical staff nurses.

2. The facility failed to establish a master NSP which was approved by a NSC composed of at least 60 percent clinical staff nurses and included strategies to help promote the health, safety and welfare of employees and patients.

a. According to the Master Nurse Staffing Plan and Nurse Staffing Committee policy, the master NSP will be developed by the NSC annually. The master NSP will align with patient acuity levels and the master NSP must be voted on and recommended by at least 60 percent of the NSC.

i. The Nurse Staffing and Oversight Committee meeting minutes were reviewed from meetings held on 6/23/22 and 8/19/22 and revealed no evidence a master NSP had been developed and approved by a NSC that consisted of at least 60 percent clinical staff nurses.

ii. Document review of the Nurse Staffing and Oversight Committee meeting minutes for 6/23/22 revealed a Master Nurse Staffing Grid was presented at the meeting by the program chief nurse (PCN) #4.

The Master Nurse Staffing Grid was reviewed and revealed the staffing grid listed the maximum patient census available on each patient unit, the nurse-to-patient ratio required for each patient unit and the acuity level designated for each patient unit. Further review revealed the Master Nurse Staffing Grid lacked evidence of strategies implemented by the facility to promote the health, safety, and welfare of the facility's employees and patients.

According to the action section of the meeting minutes, the Master Nurse Staffing Grid was approved on 6/23/22, however, only one of the 23 staff members present were clinical staff nurses.

b. An interview was conducted with PCN #4 on 12/29/22 at 9:45 a.m. PCN #4 stated the Master Nurse Staffing Grid was considered to be the master nurse staffing plan at the facility. PCN #4 stated the Master Nurse Staffing Grid had to be approved by the NSC and the NSC must be composed of 60 percent clinical staff nurses. However, PCN #4 stated the NSC did not consist of 60 percent clinical staff nurses when the Nurse Staffing and Oversight Committee meeting met on 6/23/22.

c. On 12/29/22 from 4:19 p.m. to 5:13 p.m., an interview was conducted with the chief executive officer (CEO) #2 and the chief quality officer (CQO) #3.

i. During the interview, CEO #2 stated the facility had not developed a master nurse staffing plan. CEO #2 stated the facility considered the Master Nurse Staffing Grid as the master nursing plan. CEO #2 then stated the Master Nurse Staffing Grid lacked the regulatory requirements in accordance with the Chapter 4 regulations for Nurse Staffing Plans. Additionally, CEO #2 stated the Master Nurse Staffing Grid did not outline a process or guideline on strategies that promoted the health, safety, and welfare of the facility's staff and patients.

ii. During the interview, CQO #3 stated the Master Nurse Staffing Grid was a resource used to assist with determining staffing requirements for each patient unit. However, she further stated the Master Nurse Staffing Grid was not a master nurse staffing plan. CQO #3 stated the facility did not have a master nurse staffing plan.