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Based on policy review and interview it was determined the facility's chief nursing officer failed to establish and / or review nursing services policies to ensure the policies for the provision of nursing services were reviewed and up-to-date with current nursing standards of care.


Findings include:


On 03/09/2015 at 9:00 a.m. a request for all the facility policies regarding nursing services including medication administration was requested. The following policies were supplied:

1. Ordering & Prescribing Medication, #10-02, Last reviewed 12/2013
2. Admission Nursing Assessment, #NS-13, Last reviewed 08/2013
3. Pharmacist Review of Orders, #11-01b, Last reviewed 02/2014
4. Read-Back of Verbal / Telephone Orders and Critical Tests, #NPSG 2A, Last reviewed 01/2009
5. Routine Vital Signs, #NS-36, Last reviewed 10/2010
6. Skin Integrity Assessment and Interventions, #NS-206, Last reviewed 10/2013
7. Colostomy Care-Changing Appliance, #003-NS-238, Last reviewed 01/2009,
8. Notification of Physicians of Changes in Patient Condition, #003-NS-301, Last reviewed 01/2010,
9. Patient Plan of Care, NS-7, Last reviewed 01/2009
10. Ordering and Prescribing Medication, #10-02, Last reviewed 12/2013,
11. Dispensing: General, #11-01, Last reviewed 12/2013

A review of the above policies revealed the policies had not been reviewed annually. An interview with the Chief Nursing Officer on 03/09/2015 at 2 p.m. confirmed the above findings.