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LIFECARE HOSPITALS OF NORTH TEXAS
QUALITY IMPROVEMENT ACTIVITIES
Tag No.: A0283
Based on interview and record review, the hospital did identify opportunities for improvement in that the following was not carried out:
1) The Nurse Staffing Committee did not meet quarterly as required, citing for 3 of 3 years (2019, 2020, and 2021).
2) The nurses were not educated about Safe Harbor, citing 9 of 9 nurses (Personnel #8 through Personnel #16).
Findings included:
1) The Nurse Staffing Committee did not meet quarterly as required. The hospital policy reflected "Nurse Staffing Plan, reviewed on 12/09/20, pages 1, 2, 4, & 6 "...The Staffing Effectiveness Plan...The Nurse Staffing Committee defined by Texas Health and Safety Code, Section 257.001..." The policy further indicated The Committee meets at a minimum bi-annually.
According to the Texas Health and Safety Code, Section 257.001-Nurse Staffing to 257.004, the Nurse Staffing Committee shall meet at least quarterly.
In an interview on 01/31/22 at 12:00 PM, Personnel #4 confirmed that the Nurse Staffing Committee only met twice in 2021. The Committee did not meet in 2019 and 2020. On 02/01/22 at 11:30 AM, Personnel #2 confirmed the above information.
2) The nurses were not educated about Safe Harbor, citing 9 of 9 nurses (Personnel #8 through Personnel #16). During orientation, Safe Harbor was not part of the education. On 01/07/22 many of the nurses did not understand the purpose of safe harbor. One of the nurses went on to the Texas BON (board of nursing) website to read what safe harbor entailed and shared the information to the group.
Hospital policy on "General Hospital Orientation" effective date 11/14/2019 did not include Safe Harbor. The policy indicated "...In order to provide all new employees...the opportunity to be introduced to the philosophy and objectives of the facility and to help him/her adjust to a new organization, environment and duties through a planned introduction, the new individual will complete General Hospital Orientation.
In an interview on 02/01/22 at 10:27 AM, Personnel # 2 and #4 confirmed the nursing staff did not undergo Safe Harbor education during the orientation.