HospitalInspections.org

Based on review of hospital policies and procedures and staff interview, the hospital failed to ensure that policies were reviewed annually.

Findings:

The hospital policy, "General Employment: Policy Review"(Section: 100, Code No: 126) was reviewed. It directed, "All Skyline Hospital and Departmental policy and procedures will be reviewed annually by the Policy Review Committee." There was no date on the policy.

Review of hospital nursing policies revealed that staff were not reviewing them annually. For example, the procedures for IV Therapy were documented as reviewed in June 2009, then again in March 2011. The "Transfusion of Packed Cells" procedure was dated as last reviewed in February 2001 (over 10 years ago); "Transfusion of fresh Frozen Plasma" was dated as last reviewed in December 2007 (over 3 years ago).

Staff interview on 3/29/2011 verified that policy review had not been completed annually.

There was no evidence that the hospital's group of professional personnel, the Policy Review Committee, or other nursing staff had reviewed the policies and procedures as required to guide personnel and periodically revise to reflect current practice.