NAC449.313. Responsibilities and duties of governing body; bylaws; appointment and duties of chief executive officer; protocol for organ donations; annual operating budget.

     1. A hospital shall have an effective governing body which is legally responsible for the conduct of the hospital.

     2. The governing body of a hospital shall adopt a workable set of bylaws which must be in writing and available to all members. The governing body shall:

     (a) Determine, in accordance with state law, which categories of practitioners are eligible for appointment to the medical staff of the hospital;

     (b) Appoint members to the medical staff after considering the recommendations of the existing members of the medical staff;

     (c) Ensure that the medical staff has bylaws;

     (d) Approve the bylaws of the medical staff and any other rules and regulations adopted by the medical staff;

     (e) Ensure that the medical staff is accountable to the governing body for the quality of care which the medical staff provides to patients; and

     (f) Ensure that the criteria for the selection of members to the medical staff include competence, training, experience and judgment.

     3. The governing body shall appoint a qualified chief executive officer using as its criteria the actual experience, nature and duration of hospital administration and graduate work in hospital administration of the appointee. Following his or her selection, the chief executive officer is responsible for the management of the hospital and for providing liaisons among the governing body, medical staff, nursing staff and other departments, units and services within the hospital. The chief executive officer shall keep the governing body fully informed of the conduct of the hospital through regular written reports. The chief executive officer must be allowed sufficient freedom from other responsibilities to provide adequate attention to the administration and management of the hospital.

     4. The governing body shall ensure, in accordance with hospital policy, that:

     (a) Each patient is under the care of at least one of the following persons:

          (1) A doctor of medicine or osteopathy.

          (2) A doctor of dental surgery or dental medicine who is licensed to practice dentistry in this State and who is acting within the scope of his or her license.

          (3) A doctor of podiatric medicine, but only with respect to those functions which he or she is licensed to perform in this State.

          (4) A doctor of optometry who is licensed to practice optometry in this State.

          (5) A chiropractor who is licensed to provide chiropractic services in this State, but only with respect to the treatment of the spine by means of manual manipulation to correct a subluxation which is demonstrated by X-ray to exist.

     (b) A doctor of medicine or osteopathy is on duty or on call at all times.

     (c) A doctor of medicine or osteopathy is responsible for the care of each patient with respect to any medical or psychiatric problem that:

          (1) Is present when the patient is admitted into the hospital or develops after the patient is admitted; and

          (2) Is not specifically within the scope of practice of a doctor of dental surgery, dental medicine, podiatric medicine or optometry, or of a chiropractor, as that scope of practice is defined by the bylaws, rules and regulations of the medical staff.

     5. To identify potential organ donors, a hospital shall have written protocols that:

     (a) Ensure that the family of each potential donor knows of its option to donate organs or tissues, or both, or to decline to make such a donation; and

     (b) Encourage discretion and sensitivity with respect to the circumstances, views and beliefs of the families of potential donors.

     6. A hospital in which organ transplants are performed:

     (a) Must be a member of the Organ Procurement and Transplantation Network established and operated in accordance with section 372 of the Public Health Service Act, 42 U.S.C. § 274; and

     (b) Shall abide by the rules and regulations of the Organ Procurement and Transplantation Network.

     7. A hospital shall have an overall institutional plan which includes an annual operating budget that is prepared according to generally accepted accounting principles. The annual operating budget must include anticipated income and expenses, except that the hospital is not required to identify item-by-item the components of each anticipated income or expense.

     8. The governing body is responsible for the services furnished in the hospital, regardless of whether the services are furnished by staff or pursuant to contracts. The hospital shall maintain a list of contracted services which includes the scope and nature of the services provided.

     [Bd. of Health, Health Facilities Reg. Part III Ch. I § 1, eff. 10-9-69; A 8-26-74; ch. II § I, eff. 10-9-69]—(NAC A by R050-99, 9-27-99)