HospitalInspections.org

Based on interview and policy review, the facility failed to incorporate an advisory group to conduct reviews, make recommendations concerning patient care policies on an biennial basis, and have documented evidence of meeting minutes to show activities of the advisory group. This deficient practice had the potential to adversely affect all acute care and swing bed (Medicare program in which a patient can receive acute care, then if needed, Skilled Nursing care in the same facility) patients treated or admitted to the facility, by failing to direct appropriate care and services. The facility census was nine.

Findings included:

1. Review of the following facility policies showed that:
- "Tractions" was adopted on 01/04/84 and last revised in 02/1988.
- "Adverse Drug Reactions" was last revised in 01/2001.
- "Bedside Medications" was last revised in 01/2001.
- "Hyperalimentation/TPN" was last revised in 01/2001.
- "Administration of Blood and/or Blood Products" was last revised on 07/01/2011.
- "Destruction of Medication" was last revised in 11/2003.
- "Post-Operative Discharge Criteria" was adopted in 09/16/05 with no revised date.
- "Subcutaneous Infusion Set Insertion" was adopted in 04/2006 with no revised date.
- "Surgery Cleaning After a C-diff or Unknown Infection Case" was adopted on 11/24/2010 with no revised date.
- "Preoperative IV Fluid Administration" showed no effective or revised date.
- "Port A Cath Dressing Change" showed no approval and no effective or revised date.
- "Port A Cath Line Flushing" showed no approval and no effective or revised date.
- "Obtaining Blood Culture Procedure" showed no medical staff approval and was last revised on 01/26/01.
- "Epidural or Spinal Anesthesia/Narcotic" showed no medical staff approval and was last revised in 02/2001.
- "Abuse and Neglect" showed no medical staff approval and was last revised in 02/2003.
- "Bloodborne Pathogens" showed no medical staff approval and was last revised on 07/15/2004
- "Discharge Medications" showed no medical staff approval and was last revised in 01/2006.
- "Suicide Precautions" showed no medical staff approval and was last revised on 03/01/11.
- "Blood and Fluid Warming Procedure" showed no medical staff approval, was adopted in 03/2011 and had no revision date.
- "Restraints" showed no medical staff approval and was last revised in 10/2011.

During an interview on 12/04/19 at 8:45 AM, Staff O, Chief of Staff (COS), stated that:
- He believed policy revisions were triggered by the contracted third party.
- He believed policy reviews were conducted by a contracted third party.
- If a policy update or change was needed, those policies would be brought to the monthly board meetings for approval.
- The policies were inclusive and he would only make a recommendation on policy revisions if asked.
- He was unaware there was no policy for cardiac monitoring.

During an interview on 12/04/19 at 9:15 AM, Staff C, Chief Nursing Officer (CNO), stated that:
- Annual policy reviews were done by the Chief Executive Officer (CEO).
- Policy revisions, if needed, would be brought to the board meeting by the CEO, for revision approval.
- She was "aware that many of the facility's policies need to be revised."
- She was unaware that the facility had no cardiac monitoring policy.

During an interview on 12/04/19 at 9:00 AM, Staff A, CEO, stated that:
- He was solely responsible for policy and procedure review.
- There was no contracted third party that reviews policies.
- There was no policy committee that reviews policies.
- When a policy revision needs to be made, he would revise that policy, and bring it to the board for approval.
- He was unaware there was no policy for cardiac monitoring.
- He would not want to make a recommendation on cardiac monitoring expectations, he would want that recommendation to come from the clinical staff.

Based on interview and policy review, the facility failed to incorporate an advisory group to conduct reviews, make recommendations concerning patient care policies on an biennial basis and have documented evidence of meeting minutes to show activities of the advisory group. This deficient practice had the potential to adversely affect all acute care and swing bed (Medicare program in which a patient can receive acute care, then if needed, Skilled Nursing care in the same facility) patients treated or admitted to the facility, by failing to direct appropriate care and services. The facility census was nine.

Findings included:

1. Review of the following facility policies showed that:
- "Tractions" was adopted on 01/04/84 and last revised in 02/1988.
- "Adverse Drug Reactions" was last revised in 01/2001.
- "Bedside Medications" was last revised in 01/2001.
- "Hyperalimentation/TPN" was last revised in 01/2001.
- "Administration of Blood and/or Blood Products" was last revised on 07/01/2011.
- "Destruction of Medication" was last revised in 11/2003.
- "Post-Operative Discharge Criteria" was adopted in 09/16/05 with no revised date.
- "Subcutaneous Infusion Set Insertion" was adopted in 04/2006 with no revised date.
- "Surgery Cleaning After a C-diff or Unknown Infection Case" was adopted on 11/24/2010 with no revised date.
- "Preoperative IV Fluid Administration" showed no effective or revised date.
- "Port A Cath Dressing Change" showed no approval and no effective or revised date.
- "Port A Cath Line Flushing" showed no approval and no effective or revised date.
- "Obtaining Blood Culture Procedure" showed no medical staff approval and was last revised on 01/26/01.
- "Epidural or Spinal Anesthesia/Narcotic" showed no medical staff approval and was last revised in 02/2001.
- "Abuse and Neglect" showed no medical staff approval and was last revised in 02/2003.
- "Bloodborne Pathogens" showed no medical staff approval and was last revised on 07/15/2004
- "Discharge Medications" showed no medical staff approval and was last revised in 01/2006.
- "Suicide Precautions" showed no medical staff approval and was last revised on 03/01/11.
- "Blood and Fluid Warming Procedure" showed no medical staff approval, was adopted in 03/2011 and had no revision date.
- "Restraints" showed no medical staff approval and was last revised in 10/2011

During an interview on 12/04/19 at 8:45 AM, Staff O, Chief of Staff (COS), stated that:
- He believed policy revisions were triggered by the contracted third party.
- He believed policy reviews were conducted by a contracted third party.
- If a policy update or change was needed those policies would be brought to the monthly board meetings for approval.
- The policies were inclusive and he would only make a recommendation on policy revisions if asked.
- He was unaware there was no policy for cardiac monitoring.

During an interview on 12/04/19 at 9:15 AM, Staff C, Chief Nursing Officer (CNO), stated that:
- Annual policy reviews were done by the Chief Executive Officer (CEO).
- Policy revisions, if needed, would be brought to the board meeting, by the CEO, for revision approval.
- She was "aware that many of the facility's policies need to be revised."
- She was unaware that the facility had no cardiac monitoring policy.

During an interview on 12/04/19 at 9:00 AM, Staff A, CEO, stated that:
- He was solely responsible for policy and procedure review.
- There was no contracted third party that reviews policies.
- There was no policy committee that reviews policies.
- When a policy revision needs to be made, he would revise that policy, and bring it to the board for approval.
- He was unaware there was no policy for cardiac monitoring.
- He would not want make a recommendation on cardiac monitoring expectations, he would want that recommendation to come from the clinical staff.