HospitalInspections.org

Based on record review and interview the facility failed to meet the Condition of Participation to ensure the nursing staff was provided with policies and procedures. This deficient practice could possibly result in or could lead to inconsistent decision making, variable accountability, and unstable expectations for all staff delivering direct patient care.

The findings are:

A. The facility failed to provide the nursing staff with written policies covering the health care services that are furnished in the Critical Access Hospital (CAH),(policies regarding disinfection, biohazard removal, medication administration, patient privacy and confidentiality, social media use, infectious disease, and code of ethics), which are necessary to maintain patient safety, provide a framework for decision making, and reduce the risk of errors for all patients receiving direct patient care. Refer to tag C-1006.

Based on interviews and observations, the facility failed to have written policies and procedures for the nursing staff who provide direct patient care which are necessary to maintain patient safety, provide a framework for decision making, and reduce the risk of errors for all patients receiving direct patient care. This deficient practice could result in errors in critical aspects of care including infection control, medication administration, and integration of new knowledge into practice resulting in potential serious harm, injury, or death.

The findings are:

A. During an interview on 06/10/25 at 8:40 am, S (staff)7, clinical, stated the facility has failed to provide the nursing staff with policies and procedures in written form or on the hospital intranet.

B. During an interview on 06/10/25 at 3:00 pm, S3, clinical, stated there were policies and procedures available for all staff who provide direct patient care to consult and review.

C. During a guided tour of the nursing units with S3, clinical, on 06/10/25 at 3:20 pm, no policy and procedure manual were found on the medical surgical unit, the house supervisors office, or the intensive care unit (ICU).

D. During an interview with S12, clinical, on 06/11/25 at 11:15 am, S12 stated that if he needed to access policies and procedures, he would find them in the office belonging to S1,non-clinical.

E. During an interview with S1,nonclinical, on 06/11/25 at 1:00 pm, S1 stated the policy and procedure manual were not kept in her office. S1 stated the policies could be found in the office belonging to S2, non-clinical.

F. During an interview on 06/11/25 at 1:30 pm, S2, non-clinical, stated he did not have any policies and procedure binders in his office. S2 stated there are currently no policies or procedures available on paper or the intranet.