HospitalInspections.org

Based on record review and interview, the facility failed to solicit and receive input from nurses on an ongoing basis to develop, monitor and evaluate a nursing plan in that: 1) There were no Nurse Advisory Committee meeting minutes for the year 2020. 2) The med-surg (medical-surgical) unit and the ICU (intensive care unit) unit did not have a separate staffing matrix for each unit.

Findings included:

1) On the afternoon of 10/21/2020 a review of the notebook that held nursing meeting minutes revealed there were no Nurse Advisory Committee meeting minutes for 2020.

During an interview on 10/21/2020 at 2:00 PM with Personnel #2 she confirmed there were no Nursing Advisory Committee meeting minutes included in the notebook. She said she would look for them. A search for the meeting minutes did not result in finding any documented Nurse Advisory Meeting minutes for the year 2020.

2) A review of the nursing department's 2 nursing matrices indicated one matrix was to be used if there were greater than 3 ICU patients. The other matrix was to be used if there were less than 3 ICU patients. The matrices were applied to all nursing units as one whole unit (medical surgical unit plus the ICU unit). There was not a separate individual matrix for the medical-surgical unit or for the ICU unit.

During an interview on 10/21/2020 at 10:31 AM with Personnel #1 she said there was no staffing matrix for each unit, only for the nursing department as a whole. Personnel #2 confirmed this. They could not provide a policy indicating separate matrices were applied to separate nursing units.