HospitalInspections.org

Based on review of facility policies and interview of staff, the facility failed to ensure mid-level practitioners participated in the development and review of facility policies. This failure had the potential for missing valuable insights by direct patient care providers into the creation and updating of policies and procedures which were meant to ensure consistent standards of care for all patients in the facility.

Findings Include:

Review of policy manuals for Swing Beds, Nursing, Infection Control, Surgery, Environmental Services, Dietary, and Maintenance revealed no signatures of mid-level practitioners.

Review of the staffing list for the facility revealed six Advanced Practice Registered Nurses (APRNs) were currently practicing in the facility, APRNs 12, 13, 14, 15, 16, and 17.

During an interview with the Facility Administrator on 01/16/19 at 11:10 AM, the Facility Administrator was asked if mid-level practitioners were involved in the development and review of facility policies and procedures. The Facility Administrator stated, "No," and stated that the facility planned to include these practitioners in the policy development process in the future. The Facility Administrator was unable to provide a facility policy addressing the inclusion of mid-level practitioners in the policy development or review process.