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WHITMAN HOSPITAL AND MEDICAL CENTER

1200 WEST FAIRVIEW

COLFAX, WA 99111

PATIENT CARE POLICIES

Tag No.: C1008

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Based on document review and interview, the Critical Access Hospital failed to ensure that policies and procedures were developed with the advice of members of the professional healthcare staff including at least one medical doctor.

Failure to include all members of the professional healthcare staff in policy development risks inappropriate and substandard care that results in patient harm or death.

Findings included:

1. On 04/04/23 at 8:00 AM, Surveyor #4 requested copies of the Standards of Care policies for the Emergency Department, Labor and Delivery, Post Partum, Newborn, Medical Surgical, Progressive Care Unit and Surgical Services.

2. The following policies were provided:

a. Emergency Department Standards of Care, Policy Stat ID 13340162, last approved 03/23.

b. Standards of Care for Labor and Delivery, Policy Stat ID 13344984, last approved 03/23.

c. Standards of Care Post Partum Procedure, Policy Stat ID 13390921, last approved 03/23.

d. Newborn Standards of Care Procedure, Policy Stat ID 13425867, last approved 04/23.

e. Standards of Care Surgery, Policy Stat ID 13329496, last approved 03/23.

f. Standards of Care Medical Unit, Policy Stat ID 13330665, last approved 03/23.

g. Progressive Care Unit Standards of Practice and Procedure, Policy Stat ID 13332110, last approved 04/23.

3. On 04/05/23 at 8:45 AM, Surveyors #2, #4, and #5 interviewed Chief Nursing Officer (Staff #902), Director of Quality (Staff #903), and Director of Inpatient Services (Staff #904) regarding the process for the development of the policies above. Surveyor #9 asked specifically if physicians were involved in the development of the Standards of Care for Labor and Delivery. Staff #904 stated that management created the policy with input from nursing staff and gave it to a physician for verbal approval. Staff #904 stated that physicians had not provided input in the development of the policy. Surveyor #9 asked if any of the above listed policies had been approved by the medical staff. Staff #903 stated that none of the medical staff had approved the policies.
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