HospitalInspections.org

Based on staff interviews and facility record review, the facility failed to provide a non-hospital staff member on the Patient Care Policy Committee, the provision of policy developmentThe findings include:
An interview was conducted with the Vice President of Nursing Services (VPNS) on 05/8/2013 at 10:55 a.m. The VPNS explained the policy and procedures were evaluated for additional development and revisions on an annual basis. The VP explained the group contained multiple department staff. A list of the group participating in the policy process was presented at 11:10 a.m. The list was reviewed for a non-facility staff member. The VPNS stated, "The group is made up of all staff members. I did not realize we needed a non -employee in the group."