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Based on policy and procedures review, review of records and interview, the facility failed to ensure that the nursing department provided written standards of nursing practice to define and describe the scope and conduct of patient care provided by the nursing staff and ensure the policies and procedures were reviewed annually, revised as necessary, dated to indicate the time of the last review, signed by the responsible reviewing authority, and enforced for 5 of 5 Sampled Patients (SP). SP#1, SP#2, SP#3, SP#4, and SP#5

Findings include:

The "Standards of Nursing Practice" policy was requested by the surveyor on 06/06/2023. The facility provided SOP: Nursing Assessment and Care Plan.

During the exit conference on 06/07/2023 at 3:30 PM, the facility was provided an opportunity to provide the "Standards of Nursing Practice" policy after post exit as the team was occasionally having difficulty locating documents. The request was confirmed by the Executive Director of Accreditation. The surveyor received a fax transmission on 06/09/2023 from the facility Risk Management (RM) department containing additional flowsheet documentation, and SOP: Nursing Assessment and Care Plan which was previously obtained.

A follow-up call was placed to RM1 (lead risk manager) on 06/28/2023 at 1:30 PM regarding the "Standards of Nursing Practice" policy requested. RM1 stated that the old policy was difficult to locate on the computer but a draft copy of the policy was available.

The facility did not provide a current, active policy for the "Standards of Nursing Practice" as requested.